32 Extremity trauma

Achilles tendon rupture
Achilles tendon rupture
Complete rupture of the Achilles tendon is a common injury; 20% of  acute injuries are missed. Active plantarﬂexion of  the ankle is still possible, although weak, through the use of  the toe plantarﬂexors. A classic history is a feeling of being kicked in the heel and feeling something go. The most common activity leading to Achilles tendon rupture is badminton or squash following sudden forced contraction of  the calf. On examination a palpable gap may be felt. The diagnosis is conﬁrmed b y placing the patient prone on the examination couch, feet o ﬀ the edge of  the bed; squeezing the calf  fails to elicit passive plantarﬂexion of  the foot. If doubt exists, an ultrasound can conﬁrm the diagnosis. Treatment of  acute Achilles tendon rupture involves surgi cal repair or functional management. There is an increasing trend to functional management as opposed to direct surgical repair.
Talus
Os
calcis
(b)
Talus
Os
calcis
Figure 32.27
Axial
(a)
and sagittal
(b)
views of a displaced intra-articular fracture of the os calcis.
tion. Both the overall shape and the articular surface have been restored.
Achilles tendon rupture
Complete rupture of the Achilles tendon is a common injury; 20% of  acute injuries are missed. Active plantarﬂexion of  the ankle is still possible, although weak, through the use of  the toe plantarﬂexors. A classic history is a feeling of being kicked in the heel and feeling something go. The most common activity leading to Achilles tendon rupture is badminton or squash following sudden forced contraction of  the calf. On examination a palpable gap may be felt. The diagnosis is conﬁrmed b y placing the patient prone on the examination couch, feet o ﬀ the edge of  the bed; squeezing the calf  fails to elicit passive plantarﬂexion of  the foot. If doubt exists, an ultrasound can conﬁrm the diagnosis. Treatment of  acute Achilles tendon rupture involves surgi cal repair or functional management. There is an increasing trend to functional management as opposed to direct surgical repair.
Talus
Os
calcis
(b)
Talus
Os
calcis
Figure 32.27
Axial
(a)
and sagittal
(b)
views of a displaced intra-articular fracture of the os calcis.
tion. Both the overall shape and the articular surface have been restored.
Achilles tendon rupture
Complete rupture of the Achilles tendon is a common injury; 20% of  acute injuries are missed. Active plantarﬂexion of  the ankle is still possible, although weak, through the use of  the toe plantarﬂexors. A classic history is a feeling of being kicked in the heel and feeling something go. The most common activity leading to Achilles tendon rupture is badminton or squash following sudden forced contraction of  the calf. On examination a palpable gap may be felt. The diagnosis is conﬁrmed b y placing the patient prone on the examination couch, feet o ﬀ the edge of  the bed; squeezing the calf  fails to elicit passive plantarﬂexion of  the foot. If doubt exists, an ultrasound can conﬁrm the diagnosis. Treatment of  acute Achilles tendon rupture involves surgi cal repair or functional management. There is an increasing trend to functional management as opposed to direct surgical repair.
Talus
Os
calcis
(b)
Talus
Os
calcis
Figure 32.27
Axial
(a)
and sagittal
(b)
views of a displaced intra-articular fracture of the os calcis.
tion. Both the overall shape and the articular surface have been restored.

Ankle fractures
Ankle fractures
Ankle fractures are very common. As with all intra-articular fractures one should strive for an anatomical reduction. Because of  the biconvex saddle shape of  the articular surface, small amounts of  talar shift signiﬁcantly increase joint surface contact pressures. It is useful to think of  the ankle mortise as having three col umns: medial, lateral and posterior. Each column has a bony and a soft-tissue component. On the lateral side there are the lateral malleolus, lateral collateral ligament and syndesmotic ligaments. On the medial side there are the medial malleolus and medial collateral ligament (deltoid ligament). The poste rior column has the posterior syndesmotic ligaments attached from the lateral part of  the posterior malleolus to the posterior lateral malleolus. If  only one column (either the bony or soft-tissue compo nent) has been injured, then it is considered a stable injury and can be treated non-operatively with cast or splint protection f or 6–8 weeks. If both or all three columns are in volved or there is evi dence of  talar shift, it is an unstable injury . Depending on the patient’s age and risk factors for wound complications, in gen eral unstable fractures are treated with open reduction and rigid ﬁxation to hold the fracture anatomically . Non-operative treatment may be used for unstable fractures in elderly patients or patients with poor skin and unfavourable soft tissues, but this appr oach requires close observation and careful attention to casting technique. Jacques Lisfranc de St Martin , 1790–1847, Professor of  Surgery and Operative Medicine, Paris, France. The os calcis injury is most frequently caused by a fall from a height. It is important to exclude associated injuries to the lumbar spine, which occur in 20% of  cases. Most os calcis fractures involve the posterior facet of  the subtalar joint. The severity of  the injury is often best appreciated with CT scans ( Figure 32.27 ). Treatment depends on the severity of  the injury to the subtalar joint and widening of  the heel leading to peroneal impingement. An os calcis fracture is a signiﬁcant injury and outcomes following surgical or non-operative treatment are unpredictable. On occasion in severe injuries, primary fusion of  the subtalar joint may be considered. Ankle fractures
Ankle fractures are very common. As with all intra-articular fractures one should strive for an anatomical reduction. Because of  the biconvex saddle shape of  the articular surface, small amounts of  talar shift signiﬁcantly increase joint surface contact pressures. It is useful to think of  the ankle mortise as having three col umns: medial, lateral and posterior. Each column has a bony and a soft-tissue component. On the lateral side there are the lateral malleolus, lateral collateral ligament and syndesmotic ligaments. On the medial side there are the medial malleolus and medial collateral ligament (deltoid ligament). The poste rior column has the posterior syndesmotic ligaments attached from the lateral part of  the posterior malleolus to the posterior lateral malleolus. If  only one column (either the bony or soft-tissue compo nent) has been injured, then it is considered a stable injury and can be treated non-operatively with cast or splint protection f or 6–8 weeks. If both or all three columns are in volved or there is evi dence of  talar shift, it is an unstable injury . Depending on the patient’s age and risk factors for wound complications, in gen eral unstable fractures are treated with open reduction and rigid ﬁxation to hold the fracture anatomically . Non-operative treatment may be used for unstable fractures in elderly patients or patients with poor skin and unfavourable soft tissues, but this appr oach requires close observation and careful attention to casting technique. Jacques Lisfranc de St Martin , 1790–1847, Professor of  Surgery and Operative Medicine, Paris, France. The os calcis injury is most frequently caused by a fall from a height. It is important to exclude associated injuries to the lumbar spine, which occur in 20% of  cases. Most os calcis fractures involve the posterior facet of  the subtalar joint. The severity of  the injury is often best appreciated with CT scans ( Figure 32.27 ). Treatment depends on the severity of  the injury to the subtalar joint and widening of  the heel leading to peroneal impingement. An os calcis fracture is a signiﬁcant injury and outcomes following surgical or non-operative treatment are unpredictable. On occasion in severe injuries, primary fusion of  the subtalar joint may be considered. Ankle fractures
Ankle fractures are very common. As with all intra-articular fractures one should strive for an anatomical reduction. Because of  the biconvex saddle shape of  the articular surface, small amounts of  talar shift signiﬁcantly increase joint surface contact pressures. It is useful to think of  the ankle mortise as having three col umns: medial, lateral and posterior. Each column has a bony and a soft-tissue component. On the lateral side there are the lateral malleolus, lateral collateral ligament and syndesmotic ligaments. On the medial side there are the medial malleolus and medial collateral ligament (deltoid ligament). The poste rior column has the posterior syndesmotic ligaments attached from the lateral part of  the posterior malleolus to the posterior lateral malleolus. If  only one column (either the bony or soft-tissue compo nent) has been injured, then it is considered a stable injury and can be treated non-operatively with cast or splint protection f or 6–8 weeks. If both or all three columns are in volved or there is evi dence of  talar shift, it is an unstable injury . Depending on the patient’s age and risk factors for wound complications, in gen eral unstable fractures are treated with open reduction and rigid ﬁxation to hold the fracture anatomically . Non-operative treatment may be used for unstable fractures in elderly patients or patients with poor skin and unfavourable soft tissues, but this appr oach requires close observation and careful attention to casting technique. Jacques Lisfranc de St Martin , 1790–1847, Professor of  Surgery and Operative Medicine, Paris, France. The os calcis injury is most frequently caused by a fall from a height. It is important to exclude associated injuries to the lumbar spine, which occur in 20% of  cases. Most os calcis fractures involve the posterior facet of  the subtalar joint. The severity of  the injury is often best appreciated with CT scans ( Figure 32.27 ). Treatment depends on the severity of  the injury to the subtalar joint and widening of  the heel leading to peroneal impingement. An os calcis fracture is a signiﬁcant injury and outcomes following surgical or non-operative treatment are unpredictable. On occasion in severe injuries, primary fusion of  the subtalar joint may be considered.

Bony injury
Bony injury
Description Describing the bony injury depends on several characteristics and includes the: /uni25CF name of  the bone that has been injured; /uni25CF region of  bone injured (epiphysis, metaphysis, diaphysis); /uni25CF pattern of  fracture line: transverse, oblique, spiral, seg mental or multifragmentary ( Figure 32.5 ); Sir Herbert J Seddon , trained at St Bartholomew’s Hospital, London University and the Royal National Orthopaedic Hospital, Stanmore, UK. He became the second Nu ﬃ eld Professor of  Orthopaedic Surgery in Oxford, UK. Augustus Volney Waller , 1816–1870, general practitioner of  Kensington, London, UK (1842–1851), subsequently worked as a physiologist in Bonn, Germany; Paris, France; Birmingham, UK; and Geneva, Switzerland. /uni25CF presence of compression: compression fractures occur when cancellous bone collapses; for example, vertebral wedge compression fracture; /uni25CF presence of  displacement of  the fracture fragments: undis - placed or displaced; - /uni25CF type and degree of  displacement: shortening, translation, angulation, rotation (mnemonic STAR) ( Figure 32.5 ); occasionally , the magnitude of  rotational displacement can be quite dramatic ( Figure 32.6 ) or, indeed, very subtle to assess on a radiograph – hence the need for standardised - radiographs assessing the area in question and the joint - above and below , but also clinical corroboration; /uni25CF presence of  pre-existing pathology (e.g. fracture through a tumour or in close proximity to a joint replacement); associated joint pathology: dislocation or subluxation. - In children and adolescents the fracture line may be incom - plete because of  the plastic, less brittle nature of  their bones - ( Figure 32.7 ). These incomplete fractures are called greenstick ( Figure 32.8 ) fractures, where one tension cortex fails. If the compression cortex buckles, they are called torus ( Figure 32.9 ) th. or buckle fractures. Paediatric bone may also simply undergo plastic deformation without a visible fracture line. Summary box 32.2 Describing an injury /uni25CF /uni25CF - /uni25CF
Spiral
Oblique
Tr
ansverse
Segmental
(b)
Shortenin
g
T
ranslation
Angulation
Rotation
Figure 32.5
Descriptive terms for fractures
(a)
and type of displace
ment
(b)
.
Use plain language to describe:
Location
Soft-tissue component
Bony injury
(c) (a) (d) (b) Classiﬁ  cation For each speciﬁc bony injury there may be several injury speciﬁc classiﬁcation systems. AO classiﬁcation The AO (Arbeitsgemeinschaft für Osteosynthesefragen) system provides a comprehensive classiﬁcation of  all fractures ( Figure 32.10 ). The ﬁrst number deﬁnes the bone injured and the second number the segment of  bone injured: prox imal metaphysis, diaphysis, distal metaphysis. The letter and number that follows further deﬁnes the nature of  the injury AO , Arbeitsgemeinschaft für Osteosynthesefragen, may be translated from the German as ‘Working Party on Problems of  Bone Repair’. - -
Figure 32.6
Describing fractures: the importance of rotation.
/uni00A0
(a)
Anteroposterior (AP) view of the knee seen at the top of the radio-
graph and lateral view of the ankle at the bottom, showing a spiral
fracture at the junction of the middle and distal thirds of the tibia.
/uni00A0
(b)
AP radiograph of the ankle on the same patient. Note the varied
diameter of the fracture fragments; this implies rotational deformity.
The distal fragment has translated laterally by 50%. There is no signif
icant angulation on this view.
Figure 32.7
Types of bony injury:
(a)
uninjured bone;
(b)
adult trans
verse fracture failure across the whole bone;
(c)
greenstick fracture;
the bone has failed on the tension side;
(d)
torus or buckle fracture;
the bone has failed on the compression side.
Figure 32.8
Greenstick fractures take their name from the way in
which a ‘green’ stick (one that is alive and has sap
/f_l
owing through
it) breaks.
Torus
Figure 32.9
Torus fractures take their name from an architectural
torus, which is the ‘bulge’ at the base of a column.
1 Proximal
metaphysis
Humerus
1
2 Diaphysis
3 Distal
Radius
metaphysis
and ulna 2
Femur 3
3 Distal
metaphysis
Tibia 4
4 Malleolar
segment
Figure 32.10
The AO classi
/f_i
cation system: the
/f_i
rst two numbers
specify the site of the fracture.
(a) (b) (c) ( Figure 32.11 ). For example, the previously described humeral fracture would be 12-A1 (1 humerus, 2 diaphysis, A simple, 1 /uni00A0 spiral). (For more detail see Further reading .) Growth plate injury classiﬁcation In child and adolescent injuries involvement of the growth plate (physis) can lead to abnormal growth or growth arrest, either complete or partial. Complete growth arrest will result in length abnormalities and partial growth arrest might result in angular deformities. The severity of  injury to the physis is classiﬁed in the Salter–Harris classiﬁcation, which considers whether the fracture line passes through the epiphysis, physis, metaphysis or combinations of  all the above. Salter–Harris described ﬁve and Mercer Rang added the sixth ( Figure 32.12 /uni25CF Type I – simple fracture line just involving the physis. Sel dom a ﬀ ects growth. /uni25CF Type II – fracture line through the physis exiting through the metaphysis, producing a metaphyseal fragment. Sel dom a ﬀ ects growth. /uni25CF Type III – fracture line through the physis exiting through the epiphysis (intra-articular). Seldom a ﬀ ects growth, but intra-articular a ﬀ ecting joint surface. /uni25CF Type IV – fracture line across the epiphysis, across the phy sis and across the metaphysis. This injury can cause focal fusion of  the physis, leading to abnormal growth. Robert Bruce Salter , 1924–2010, Professor of  Orthopaedic Surgery , University of  Toronto, Ontario, Canada. A pioneer in the ﬁeld of  paediatric orthopaedic surgery , he received international awards for medical science and the Distinguished Achievement for Orthopaedic Research award. W Robert Harris , 1922–2005, formerly Professor, University of  Toronto, President of  the Canadian Orthopaedic Foundation (1968) and President of  the Cana dian Orthopaedic Association (1975 and 1976). Charles Mercer Rang , 1933–2003, British orthopaedic paediatric surgeon. /uni25CF Type V – a crush injury of  the physis. Growth disturbance is common and may be the ﬁrst radiological sign of  an injury . /uni25CF Type VI – injury to perichondral structures by direct trauma. Rare injury , high chance of  abnormal growth.
A – Extra-articular
A – After reduction
complete contact
between the two
main fragments
(>95%)
B – Partial articular;
B – After
re
duction
some part of the
partial contact
joint remains in
between the two
continuity with
main fragments
the diaphysis
(wedge fracture)
C – Complete articular;
C – After
re
duction
an intra-articular
no contact
fracture with none
between the two
of the joint
main fragments
attached to the
(segmental)
diaphysis
Figure 32.11
The AO classi
/f_i
cation system: the letter de
/f_i
nes the
nature of the fracture.
IV
V
V
I
Figure 32.12
The Salter–Harris classi
/f_i
cation of growth plate injuries.
Bony injury
Description Describing the bony injury depends on several characteristics and includes the: /uni25CF name of  the bone that has been injured; /uni25CF region of  bone injured (epiphysis, metaphysis, diaphysis); /uni25CF pattern of  fracture line: transverse, oblique, spiral, seg mental or multifragmentary ( Figure 32.5 ); Sir Herbert J Seddon , trained at St Bartholomew’s Hospital, London University and the Royal National Orthopaedic Hospital, Stanmore, UK. He became the second Nu ﬃ eld Professor of  Orthopaedic Surgery in Oxford, UK. Augustus Volney Waller , 1816–1870, general practitioner of  Kensington, London, UK (1842–1851), subsequently worked as a physiologist in Bonn, Germany; Paris, France; Birmingham, UK; and Geneva, Switzerland. /uni25CF presence of compression: compression fractures occur when cancellous bone collapses; for example, vertebral wedge compression fracture; /uni25CF presence of  displacement of  the fracture fragments: undis - placed or displaced; - /uni25CF type and degree of  displacement: shortening, translation, angulation, rotation (mnemonic STAR) ( Figure 32.5 ); occasionally , the magnitude of  rotational displacement can be quite dramatic ( Figure 32.6 ) or, indeed, very subtle to assess on a radiograph – hence the need for standardised - radiographs assessing the area in question and the joint - above and below , but also clinical corroboration; /uni25CF presence of  pre-existing pathology (e.g. fracture through a tumour or in close proximity to a joint replacement); associated joint pathology: dislocation or subluxation. - In children and adolescents the fracture line may be incom - plete because of  the plastic, less brittle nature of  their bones - ( Figure 32.7 ). These incomplete fractures are called greenstick ( Figure 32.8 ) fractures, where one tension cortex fails. If the compression cortex buckles, they are called torus ( Figure 32.9 ) th. or buckle fractures. Paediatric bone may also simply undergo plastic deformation without a visible fracture line. Summary box 32.2 Describing an injury /uni25CF /uni25CF - /uni25CF
Spiral
Oblique
Tr
ansverse
Segmental
(b)
Shortenin
g
T
ranslation
Angulation
Rotation
Figure 32.5
Descriptive terms for fractures
(a)
and type of displace
ment
(b)
.
Use plain language to describe:
Location
Soft-tissue component
Bony injury
(c) (a) (d) (b) Classiﬁ  cation For each speciﬁc bony injury there may be several injury speciﬁc classiﬁcation systems. AO classiﬁcation The AO (Arbeitsgemeinschaft für Osteosynthesefragen) system provides a comprehensive classiﬁcation of  all fractures ( Figure 32.10 ). The ﬁrst number deﬁnes the bone injured and the second number the segment of  bone injured: prox imal metaphysis, diaphysis, distal metaphysis. The letter and number that follows further deﬁnes the nature of  the injury AO , Arbeitsgemeinschaft für Osteosynthesefragen, may be translated from the German as ‘Working Party on Problems of  Bone Repair’. - -
Figure 32.6
Describing fractures: the importance of rotation.
/uni00A0
(a)
Anteroposterior (AP) view of the knee seen at the top of the radio-
graph and lateral view of the ankle at the bottom, showing a spiral
fracture at the junction of the middle and distal thirds of the tibia.
/uni00A0
(b)
AP radiograph of the ankle on the same patient. Note the varied
diameter of the fracture fragments; this implies rotational deformity.
The distal fragment has translated laterally by 50%. There is no signif
icant angulation on this view.
Figure 32.7
Types of bony injury:
(a)
uninjured bone;
(b)
adult trans
verse fracture failure across the whole bone;
(c)
greenstick fracture;
the bone has failed on the tension side;
(d)
torus or buckle fracture;
the bone has failed on the compression side.
Figure 32.8
Greenstick fractures take their name from the way in
which a ‘green’ stick (one that is alive and has sap
/f_l
owing through
it) breaks.
Torus
Figure 32.9
Torus fractures take their name from an architectural
torus, which is the ‘bulge’ at the base of a column.
1 Proximal
metaphysis
Humerus
1
2 Diaphysis
3 Distal
Radius
metaphysis
and ulna 2
Femur 3
3 Distal
metaphysis
Tibia 4
4 Malleolar
segment
Figure 32.10
The AO classi
/f_i
cation system: the
/f_i
rst two numbers
specify the site of the fracture.
(a) (b) (c) ( Figure 32.11 ). For example, the previously described humeral fracture would be 12-A1 (1 humerus, 2 diaphysis, A simple, 1 /uni00A0 spiral). (For more detail see Further reading .) Growth plate injury classiﬁcation In child and adolescent injuries involvement of the growth plate (physis) can lead to abnormal growth or growth arrest, either complete or partial. Complete growth arrest will result in length abnormalities and partial growth arrest might result in angular deformities. The severity of  injury to the physis is classiﬁed in the Salter–Harris classiﬁcation, which considers whether the fracture line passes through the epiphysis, physis, metaphysis or combinations of  all the above. Salter–Harris described ﬁve and Mercer Rang added the sixth ( Figure 32.12 /uni25CF Type I – simple fracture line just involving the physis. Sel dom a ﬀ ects growth. /uni25CF Type II – fracture line through the physis exiting through the metaphysis, producing a metaphyseal fragment. Sel dom a ﬀ ects growth. /uni25CF Type III – fracture line through the physis exiting through the epiphysis (intra-articular). Seldom a ﬀ ects growth, but intra-articular a ﬀ ecting joint surface. /uni25CF Type IV – fracture line across the epiphysis, across the phy sis and across the metaphysis. This injury can cause focal fusion of  the physis, leading to abnormal growth. Robert Bruce Salter , 1924–2010, Professor of  Orthopaedic Surgery , University of  Toronto, Ontario, Canada. A pioneer in the ﬁeld of  paediatric orthopaedic surgery , he received international awards for medical science and the Distinguished Achievement for Orthopaedic Research award. W Robert Harris , 1922–2005, formerly Professor, University of  Toronto, President of  the Canadian Orthopaedic Foundation (1968) and President of  the Cana dian Orthopaedic Association (1975 and 1976). Charles Mercer Rang , 1933–2003, British orthopaedic paediatric surgeon. /uni25CF Type V – a crush injury of  the physis. Growth disturbance is common and may be the ﬁrst radiological sign of  an injury . /uni25CF Type VI – injury to perichondral structures by direct trauma. Rare injury , high chance of  abnormal growth.
A – Extra-articular
A – After reduction
complete contact
between the two
main fragments
(>95%)
B – Partial articular;
B – After
re
duction
some part of the
partial contact
joint remains in
between the two
continuity with
main fragments
the diaphysis
(wedge fracture)
C – Complete articular;
C – After
re
duction
an intra-articular
no contact
fracture with none
between the two
of the joint
main fragments
attached to the
(segmental)
diaphysis
Figure 32.11
The AO classi
/f_i
cation system: the letter de
/f_i
nes the
nature of the fracture.
IV
V
V
I
Figure 32.12
The Salter–Harris classi
/f_i
cation of growth plate injuries.
Bony injury
Description Describing the bony injury depends on several characteristics and includes the: /uni25CF name of  the bone that has been injured; /uni25CF region of  bone injured (epiphysis, metaphysis, diaphysis); /uni25CF pattern of  fracture line: transverse, oblique, spiral, seg mental or multifragmentary ( Figure 32.5 ); Sir Herbert J Seddon , trained at St Bartholomew’s Hospital, London University and the Royal National Orthopaedic Hospital, Stanmore, UK. He became the second Nu ﬃ eld Professor of  Orthopaedic Surgery in Oxford, UK. Augustus Volney Waller , 1816–1870, general practitioner of  Kensington, London, UK (1842–1851), subsequently worked as a physiologist in Bonn, Germany; Paris, France; Birmingham, UK; and Geneva, Switzerland. /uni25CF presence of compression: compression fractures occur when cancellous bone collapses; for example, vertebral wedge compression fracture; /uni25CF presence of  displacement of  the fracture fragments: undis - placed or displaced; - /uni25CF type and degree of  displacement: shortening, translation, angulation, rotation (mnemonic STAR) ( Figure 32.5 ); occasionally , the magnitude of  rotational displacement can be quite dramatic ( Figure 32.6 ) or, indeed, very subtle to assess on a radiograph – hence the need for standardised - radiographs assessing the area in question and the joint - above and below , but also clinical corroboration; /uni25CF presence of  pre-existing pathology (e.g. fracture through a tumour or in close proximity to a joint replacement); associated joint pathology: dislocation or subluxation. - In children and adolescents the fracture line may be incom - plete because of  the plastic, less brittle nature of  their bones - ( Figure 32.7 ). These incomplete fractures are called greenstick ( Figure 32.8 ) fractures, where one tension cortex fails. If the compression cortex buckles, they are called torus ( Figure 32.9 ) th. or buckle fractures. Paediatric bone may also simply undergo plastic deformation without a visible fracture line. Summary box 32.2 Describing an injury /uni25CF /uni25CF - /uni25CF
Spiral
Oblique
Tr
ansverse
Segmental
(b)
Shortenin
g
T
ranslation
Angulation
Rotation
Figure 32.5
Descriptive terms for fractures
(a)
and type of displace
ment
(b)
.
Use plain language to describe:
Location
Soft-tissue component
Bony injury
(c) (a) (d) (b) Classiﬁ  cation For each speciﬁc bony injury there may be several injury speciﬁc classiﬁcation systems. AO classiﬁcation The AO (Arbeitsgemeinschaft für Osteosynthesefragen) system provides a comprehensive classiﬁcation of  all fractures ( Figure 32.10 ). The ﬁrst number deﬁnes the bone injured and the second number the segment of  bone injured: prox imal metaphysis, diaphysis, distal metaphysis. The letter and number that follows further deﬁnes the nature of  the injury AO , Arbeitsgemeinschaft für Osteosynthesefragen, may be translated from the German as ‘Working Party on Problems of  Bone Repair’. - -
Figure 32.6
Describing fractures: the importance of rotation.
/uni00A0
(a)
Anteroposterior (AP) view of the knee seen at the top of the radio-
graph and lateral view of the ankle at the bottom, showing a spiral
fracture at the junction of the middle and distal thirds of the tibia.
/uni00A0
(b)
AP radiograph of the ankle on the same patient. Note the varied
diameter of the fracture fragments; this implies rotational deformity.
The distal fragment has translated laterally by 50%. There is no signif
icant angulation on this view.
Figure 32.7
Types of bony injury:
(a)
uninjured bone;
(b)
adult trans
verse fracture failure across the whole bone;
(c)
greenstick fracture;
the bone has failed on the tension side;
(d)
torus or buckle fracture;
the bone has failed on the compression side.
Figure 32.8
Greenstick fractures take their name from the way in
which a ‘green’ stick (one that is alive and has sap
/f_l
owing through
it) breaks.
Torus
Figure 32.9
Torus fractures take their name from an architectural
torus, which is the ‘bulge’ at the base of a column.
1 Proximal
metaphysis
Humerus
1
2 Diaphysis
3 Distal
Radius
metaphysis
and ulna 2
Femur 3
3 Distal
metaphysis
Tibia 4
4 Malleolar
segment
Figure 32.10
The AO classi
/f_i
cation system: the
/f_i
rst two numbers
specify the site of the fracture.
(a) (b) (c) ( Figure 32.11 ). For example, the previously described humeral fracture would be 12-A1 (1 humerus, 2 diaphysis, A simple, 1 /uni00A0 spiral). (For more detail see Further reading .) Growth plate injury classiﬁcation In child and adolescent injuries involvement of the growth plate (physis) can lead to abnormal growth or growth arrest, either complete or partial. Complete growth arrest will result in length abnormalities and partial growth arrest might result in angular deformities. The severity of  injury to the physis is classiﬁed in the Salter–Harris classiﬁcation, which considers whether the fracture line passes through the epiphysis, physis, metaphysis or combinations of  all the above. Salter–Harris described ﬁve and Mercer Rang added the sixth ( Figure 32.12 /uni25CF Type I – simple fracture line just involving the physis. Sel dom a ﬀ ects growth. /uni25CF Type II – fracture line through the physis exiting through the metaphysis, producing a metaphyseal fragment. Sel dom a ﬀ ects growth. /uni25CF Type III – fracture line through the physis exiting through the epiphysis (intra-articular). Seldom a ﬀ ects growth, but intra-articular a ﬀ ecting joint surface. /uni25CF Type IV – fracture line across the epiphysis, across the phy sis and across the metaphysis. This injury can cause focal fusion of  the physis, leading to abnormal growth. Robert Bruce Salter , 1924–2010, Professor of  Orthopaedic Surgery , University of  Toronto, Ontario, Canada. A pioneer in the ﬁeld of  paediatric orthopaedic surgery , he received international awards for medical science and the Distinguished Achievement for Orthopaedic Research award. W Robert Harris , 1922–2005, formerly Professor, University of  Toronto, President of  the Canadian Orthopaedic Foundation (1968) and President of  the Cana dian Orthopaedic Association (1975 and 1976). Charles Mercer Rang , 1933–2003, British orthopaedic paediatric surgeon. /uni25CF Type V – a crush injury of  the physis. Growth disturbance is common and may be the ﬁrst radiological sign of  an injury . /uni25CF Type VI – injury to perichondral structures by direct trauma. Rare injury , high chance of  abnormal growth.
A – Extra-articular
A – After reduction
complete contact
between the two
main fragments
(>95%)
B – Partial articular;
B – After
re
duction
some part of the
partial contact
joint remains in
between the two
continuity with
main fragments
the diaphysis
(wedge fracture)
C – Complete articular;
C – After
re
duction
an intra-articular
no contact
fracture with none
between the two
of the joint
main fragments
attached to the
(segmental)
diaphysis
Figure 32.11
The AO classi
/f_i
cation system: the letter de
/f_i
nes the
nature of the fracture.
IV
V
V
I
Figure 32.12
The Salter–Harris classi
/f_i
cation of growth plate injuries.

COMPARTMENT SYNDROME
COMPARTMENT SYNDROME
Compartment syndrome is raised pressure in a fascial compart - ment to a level that compromises tissue perfusion. There are several causes of  compartment syndrome, fractures being the most common (70%), followed by soft-tissue contusions (23%). Rarer causes include: bleeding disorders, including anti - coagula tion; burns (particularly circumferential third-degree burns); postischaemic swelling (reperfusion injury); tight casts/ - dressings; and extravasation of  intravenous infusions (contrast under pressur e). The pathophysiology involves increased tissue pressure, - which leads to reduced microperfusion, resulting in tissue isch - aemia and irreversible muscle damage from cellular anoxia. Compartment syndr ome is a clinical diagnosis character - ised by pain out of  proportion, increasing pain, and pain on passive stretch, with paraesthesia possible. Paralysis, numbness and pallor are /uni00A0 late signs and pulselessness is an extremely late - sign. Compartment pressure monitoring ma y be useful in cases - of  diagnostic uncertainty and in patients with altered levels of consciousness (intubated, head injury). Measure multiple sites near but not in the fracture site, in all the compartments of  the a ﬀ ected limb. Generally accepted pressur e thresholds include an absolute pressure greater than or equal to 30 /uni00A0 mmHg or pressure di ﬀ erence (diastolic pres - sure /uni00A0 – /uni00A0 compartment pressure) less than or equal to 30 /uni00A0 mmHg. Emergency treatment involves splitting casts and/or dress - ings to the skin and elevating the extremity . Senior input should be sought and arrangements put in place to perform deﬁnitive treatment with fasciotomies. There are some common pitfalls to remember. The inci - dence of  compartment syndrome associa ted with high- and low-energy injuries is nearly equal. Compartment syndrome can occur in open fractures. Have a high index of  suspicion and be particularly vigilant in patients with an altered level of consciousness. COMPARTMENT SYNDROME
Compartment syndrome is raised pressure in a fascial compart - ment to a level that compromises tissue perfusion. There are several causes of  compartment syndrome, fractures being the most common (70%), followed by soft-tissue contusions (23%). Rarer causes include: bleeding disorders, including anti - coagula tion; burns (particularly circumferential third-degree burns); postischaemic swelling (reperfusion injury); tight casts/ - dressings; and extravasation of  intravenous infusions (contrast under pressur e). The pathophysiology involves increased tissue pressure, - which leads to reduced microperfusion, resulting in tissue isch - aemia and irreversible muscle damage from cellular anoxia. Compartment syndr ome is a clinical diagnosis character - ised by pain out of  proportion, increasing pain, and pain on passive stretch, with paraesthesia possible. Paralysis, numbness and pallor are /uni00A0 late signs and pulselessness is an extremely late - sign. Compartment pressure monitoring ma y be useful in cases - of  diagnostic uncertainty and in patients with altered levels of consciousness (intubated, head injury). Measure multiple sites near but not in the fracture site, in all the compartments of  the a ﬀ ected limb. Generally accepted pressur e thresholds include an absolute pressure greater than or equal to 30 /uni00A0 mmHg or pressure di ﬀ erence (diastolic pres - sure /uni00A0 – /uni00A0 compartment pressure) less than or equal to 30 /uni00A0 mmHg. Emergency treatment involves splitting casts and/or dress - ings to the skin and elevating the extremity . Senior input should be sought and arrangements put in place to perform deﬁnitive treatment with fasciotomies. There are some common pitfalls to remember. The inci - dence of  compartment syndrome associa ted with high- and low-energy injuries is nearly equal. Compartment syndrome can occur in open fractures. Have a high index of  suspicion and be particularly vigilant in patients with an altered level of consciousness. COMPARTMENT SYNDROME
Compartment syndrome is raised pressure in a fascial compart - ment to a level that compromises tissue perfusion. There are several causes of  compartment syndrome, fractures being the most common (70%), followed by soft-tissue contusions (23%). Rarer causes include: bleeding disorders, including anti - coagula tion; burns (particularly circumferential third-degree burns); postischaemic swelling (reperfusion injury); tight casts/ - dressings; and extravasation of  intravenous infusions (contrast under pressur e). The pathophysiology involves increased tissue pressure, - which leads to reduced microperfusion, resulting in tissue isch - aemia and irreversible muscle damage from cellular anoxia. Compartment syndr ome is a clinical diagnosis character - ised by pain out of  proportion, increasing pain, and pain on passive stretch, with paraesthesia possible. Paralysis, numbness and pallor are /uni00A0 late signs and pulselessness is an extremely late - sign. Compartment pressure monitoring ma y be useful in cases - of  diagnostic uncertainty and in patients with altered levels of consciousness (intubated, head injury). Measure multiple sites near but not in the fracture site, in all the compartments of  the a ﬀ ected limb. Generally accepted pressur e thresholds include an absolute pressure greater than or equal to 30 /uni00A0 mmHg or pressure di ﬀ erence (diastolic pres - sure /uni00A0 – /uni00A0 compartment pressure) less than or equal to 30 /uni00A0 mmHg. Emergency treatment involves splitting casts and/or dress - ings to the skin and elevating the extremity . Senior input should be sought and arrangements put in place to perform deﬁnitive treatment with fasciotomies. There are some common pitfalls to remember. The inci - dence of  compartment syndrome associa ted with high- and low-energy injuries is nearly equal. Compartment syndrome can occur in open fractures. Have a high index of  suspicion and be particularly vigilant in patients with an altered level of consciousness.

CONCLUSION
CONCLUSION
The correct identiﬁcation of  extremity trauma, combined with timely and appropriate treatment, is essential to return patients to normal function as safely and as quickly as possible. The same injury may be treated in di ﬀ erent ways based on patient factors, age, functional demands and comorbidities. Surgeon and resource-based factors also need to be considered. Summary of extremity trauma /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Realise that an injury exists
Find the characteristics of the injury, describe it and classify it
Consider the natural history of the injury
Treatment is guided by outcome if known or by principle if not
Beware of injuries that are ‘easily missed’
CONCLUSION
The correct identiﬁcation of  extremity trauma, combined with timely and appropriate treatment, is essential to return patients to normal function as safely and as quickly as possible. The same injury may be treated in di ﬀ erent ways based on patient factors, age, functional demands and comorbidities. Surgeon and resource-based factors also need to be considered. Summary of extremity trauma /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Realise that an injury exists
Find the characteristics of the injury, describe it and classify it
Consider the natural history of the injury
Treatment is guided by outcome if known or by principle if not
Beware of injuries that are ‘easily missed’
CONCLUSION
The correct identiﬁcation of  extremity trauma, combined with timely and appropriate treatment, is essential to return patients to normal function as safely and as quickly as possible. The same injury may be treated in di ﬀ erent ways based on patient factors, age, functional demands and comorbidities. Surgeon and resource-based factors also need to be considered. Summary of extremity trauma /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Realise that an injury exists
Find the characteristics of the injury, describe it and classify it
Consider the natural history of the injury
Treatment is guided by outcome if known or by principle if not
Beware of injuries that are ‘easily missed’

Carpal instability
Carpal instability
The most commonly involved carpal bone is the lunate. A lunate dislocation is where the lunate bone dislocates out of the radiocarpal joint. In a perilunate dislocation the lunate remains in the radiocarpal joint and the rest of  the carpus dislocates around the lunate. Lunate and perilunate disloca tions are easily missed unless careful attention is paid to carpal alignment on the lateral radiograph ( Figure 32.22 ). Review of  the radiographs should particularly ensure the anatomical location of  the lunate in the radiocarpal fossa and tha capitate in the ‘cup’ of  the lunate is maintained. Acute injuries should be reduced closed initially to remove pressure from the median nerve. Anatomical carpal alignment is di ﬃ cult to hold and therefore sur gical reconstruction of damaged intrinsic ligaments, together with K-wire ﬁxation of the carpal bones, is often undertaken. Ligamentous healing is slow and may be incomplete. K-wires are kept in place for 8 /uni00A0 weeks and the wrist casted or splinted for 3 months. Carpal instability
The most commonly involved carpal bone is the lunate. A lunate dislocation is where the lunate bone dislocates out of the radiocarpal joint. In a perilunate dislocation the lunate remains in the radiocarpal joint and the rest of  the carpus dislocates around the lunate. Lunate and perilunate disloca tions are easily missed unless careful attention is paid to carpal alignment on the lateral radiograph ( Figure 32.22 ). Review of  the radiographs should particularly ensure the anatomical location of  the lunate in the radiocarpal fossa and tha capitate in the ‘cup’ of  the lunate is maintained. Acute injuries should be reduced closed initially to remove pressure from the median nerve. Anatomical carpal alignment is di ﬃ cult to hold and therefore sur gical reconstruction of damaged intrinsic ligaments, together with K-wire ﬁxation of the carpal bones, is often undertaken. Ligamentous healing is slow and may be incomplete. K-wires are kept in place for 8 /uni00A0 weeks and the wrist casted or splinted for 3 months. Carpal instability
The most commonly involved carpal bone is the lunate. A lunate dislocation is where the lunate bone dislocates out of the radiocarpal joint. In a perilunate dislocation the lunate remains in the radiocarpal joint and the rest of  the carpus dislocates around the lunate. Lunate and perilunate disloca tions are easily missed unless careful attention is paid to carpal alignment on the lateral radiograph ( Figure 32.22 ). Review of  the radiographs should particularly ensure the anatomical location of  the lunate in the radiocarpal fossa and tha capitate in the ‘cup’ of  the lunate is maintained. Acute injuries should be reduced closed initially to remove pressure from the median nerve. Anatomical carpal alignment is di ﬃ cult to hold and therefore sur gical reconstruction of damaged intrinsic ligaments, together with K-wire ﬁxation of the carpal bones, is often undertaken. Ligamentous healing is slow and may be incomplete. K-wires are kept in place for 8 /uni00A0 weeks and the wrist casted or splinted for 3 months.

Clavicle fractures
Clavicle fractures
Diaphyseal fractures of  the middle third of  the clavicle have traditionally been treated non-operatively with a broad arm sling for comfort and social protection, followed by increasing use of  the arm. Most mid-third fractures of  the clavicle will unite with non-operative treatment. There is, however, a subset of  clavicle may be slow to heal and that do impact on shoul - fractures that der girdle function. Displaced, comminuted fractures show a propensity to be slow to heal and increasing age and female gender further negatively impact on fracture healing. It has been shown that 2 /uni00A0 cm of  shortening of  the clavicle impacts on tigability when shoulder girdle function, with weakness and fa working above shoulder height. Internal ﬁxation with an intramedullary device or plate and screw construct can restore length, alignment and rota - functional tion. This can improve the speed and amount of restoration, but carries all the risks of  surgical treatment. Treatment is individualised to patient needs and expectations. - Clavicle fractures
Diaphyseal fractures of  the middle third of  the clavicle have traditionally been treated non-operatively with a broad arm sling for comfort and social protection, followed by increasing use of  the arm. Most mid-third fractures of  the clavicle will unite with non-operative treatment. There is, however, a subset of  clavicle may be slow to heal and that do impact on shoul - fractures that der girdle function. Displaced, comminuted fractures show a propensity to be slow to heal and increasing age and female gender further negatively impact on fracture healing. It has been shown that 2 /uni00A0 cm of  shortening of  the clavicle impacts on tigability when shoulder girdle function, with weakness and fa working above shoulder height. Internal ﬁxation with an intramedullary device or plate and screw construct can restore length, alignment and rota - functional tion. This can improve the speed and amount of restoration, but carries all the risks of  surgical treatment. Treatment is individualised to patient needs and expectations. - Clavicle fractures
Diaphyseal fractures of  the middle third of  the clavicle have traditionally been treated non-operatively with a broad arm sling for comfort and social protection, followed by increasing use of  the arm. Most mid-third fractures of  the clavicle will unite with non-operative treatment. There is, however, a subset of  clavicle may be slow to heal and that do impact on shoul - fractures that der girdle function. Displaced, comminuted fractures show a propensity to be slow to heal and increasing age and female gender further negatively impact on fracture healing. It has been shown that 2 /uni00A0 cm of  shortening of  the clavicle impacts on tigability when shoulder girdle function, with weakness and fa working above shoulder height. Internal ﬁxation with an intramedullary device or plate and screw construct can restore length, alignment and rota - functional tion. This can improve the speed and amount of restoration, but carries all the risks of  surgical treatment. Treatment is individualised to patient needs and expectations. -

DESCRIPTION AND CLASSIFICATION OF THE INJURY Soft-
DESCRIPTION AND CLASSIFICATION OF THE INJURY Soft-tissue injury
There are several classiﬁcation systems for soft-tissue injuries: the Tscherne classiﬁcation for closed injuries, the Gustilo and Anderson for open injuries ( Table 32.2 ) and the Ganga classi - ﬁcation of  severe open injuries. The ﬁrst step in soft-tissue injury characterisation is to decide if this is an open or closed fracture – an open frac - here the fracture haematoma com - ture being any fracture w municates with a breach in the epithelial lining, not just skin. For example, an open pelvic fracture may communicate with the vagina or rectum and a mandibular fracture through the mucosa of  the mouth (see Open fractures ). Consider all the soft tissues cr ossing the zone of  injury , as it is possible to get a closed rupture or avulsion of  tendons without a break in the skin. Consider the possibility of  a neuro - vascular injury (see Neurological injury ). Severe soft-tissue injur y in the presence or absence of  a fracture may still lead to compartment syndrome (see Compartment syndrome ).
24
classi
/f_i
cation.
Type
I
A low-energy open fracture with a wound less than 1
/uni00A0
cm long
and clean
II
An open fracture with a laceration more than 1
/uni00A0
cm long
without extensive soft-tissue damage,
/f_l
aps or avulsion
III
Characterised by high-energy injury irrespective of the size
of the wound. Extensive damage to soft tissues, including
muscles, skin and neurovascular structures, and a high
degree of contamination. Multifragmentary and unstable
fractures
Subgroups of type III
A
Adequate soft-tissue cover of a fractured bone after
stabilisation
B
Inadequate soft-tissue cover of a fractured bone after
stabilisation (i.e.
/f_l
ap coverage required)
C
Open fracture associated with an arterial injury requiring repair
Source: Gustilo RB, Mendoza RM, Williams DN. Problems in the
management of type III (severe) open fractures: a new classi
/f_i
cation
of type III open fractures.
J Trauma
1984;
: 742–6.
DESCRIPTION AND CLASSIFICATION OF THE INJURY Soft-tissue injury
There are several classiﬁcation systems for soft-tissue injuries: the Tscherne classiﬁcation for closed injuries, the Gustilo and Anderson for open injuries ( Table 32.2 ) and the Ganga classi - ﬁcation of  severe open injuries. The ﬁrst step in soft-tissue injury characterisation is to decide if this is an open or closed fracture – an open frac - here the fracture haematoma com - ture being any fracture w municates with a breach in the epithelial lining, not just skin. For example, an open pelvic fracture may communicate with the vagina or rectum and a mandibular fracture through the mucosa of  the mouth (see Open fractures ). Consider all the soft tissues cr ossing the zone of  injury , as it is possible to get a closed rupture or avulsion of  tendons without a break in the skin. Consider the possibility of  a neuro - vascular injury (see Neurological injury ). Severe soft-tissue injur y in the presence or absence of  a fracture may still lead to compartment syndrome (see Compartment syndrome ).
24
classi
/f_i
cation.
Type
I
A low-energy open fracture with a wound less than 1
/uni00A0
cm long
and clean
II
An open fracture with a laceration more than 1
/uni00A0
cm long
without extensive soft-tissue damage,
/f_l
aps or avulsion
III
Characterised by high-energy injury irrespective of the size
of the wound. Extensive damage to soft tissues, including
muscles, skin and neurovascular structures, and a high
degree of contamination. Multifragmentary and unstable
fractures
Subgroups of type III
A
Adequate soft-tissue cover of a fractured bone after
stabilisation
B
Inadequate soft-tissue cover of a fractured bone after
stabilisation (i.e.
/f_l
ap coverage required)
C
Open fracture associated with an arterial injury requiring repair
Source: Gustilo RB, Mendoza RM, Williams DN. Problems in the
management of type III (severe) open fractures: a new classi
/f_i
cation
of type III open fractures.
J Trauma
1984;
: 742–6.

DESCRIPTION AND CLASSIFICATION OF THE INJURY Soft-tissue injury
DESCRIPTION AND CLASSIFICATION OF THE INJURY Soft-tissue injury
There are several classiﬁcation systems for soft-tissue injuries: the Tscherne classiﬁcation for closed injuries, the Gustilo and Anderson for open injuries ( Table 32.2 ) and the Ganga classi - ﬁcation of  severe open injuries. The ﬁrst step in soft-tissue injury characterisation is to decide if this is an open or closed fracture – an open frac - here the fracture haematoma com - ture being any fracture w municates with a breach in the epithelial lining, not just skin. For example, an open pelvic fracture may communicate with the vagina or rectum and a mandibular fracture through the mucosa of  the mouth (see Open fractures ). Consider all the soft tissues cr ossing the zone of  injury , as it is possible to get a closed rupture or avulsion of  tendons without a break in the skin. Consider the possibility of  a neuro - vascular injury (see Neurological injury ). Severe soft-tissue injur y in the presence or absence of  a fracture may still lead to compartment syndrome (see Compartment syndrome ).
24
classi
/f_i
cation.
Type
I
A low-energy open fracture with a wound less than 1
/uni00A0
cm long
and clean
II
An open fracture with a laceration more than 1
/uni00A0
cm long
without extensive soft-tissue damage,
/f_l
aps or avulsion
III
Characterised by high-energy injury irrespective of the size
of the wound. Extensive damage to soft tissues, including
muscles, skin and neurovascular structures, and a high
degree of contamination. Multifragmentary and unstable
fractures
Subgroups of type III
A
Adequate soft-tissue cover of a fractured bone after
stabilisation
B
Inadequate soft-tissue cover of a fractured bone after
stabilisation (i.e.
/f_l
ap coverage required)
C
Open fracture associated with an arterial injury requiring repair
Source: Gustilo RB, Mendoza RM, Williams DN. Problems in the
management of type III (severe) open fractures: a new classi
/f_i
cation
of type III open fractures.
J Trauma
1984;
: 742–6.

DIAGNOSIS
DIAGNOSIS
The diagnosis of  extremity trauma begins with the taking of  a pertinent history followed by focused physical examination and appropriate special tests. DIAGNOSIS
The diagnosis of  extremity trauma begins with the taking of  a pertinent history followed by focused physical examination and appropriate special tests. DIAGNOSIS
The diagnosis of  extremity trauma begins with the taking of  a pertinent history followed by focused physical examination and appropriate special tests.

Diaphyseal fractures
Diaphyseal fractures
Extra-articular fractures do not require an anatomical reduc - tion, but rather a mechanical restoration by correction of length, alignment and rotation ( Figure 32.18 ). Angular malunion of  a diaphyseal fracture of  the weight-bearing long bones will lead to abnormal joint forces on the joint above and below , leading to pain and secondary degenera tive joint disease. Diaphyseal fractures are generally well suited to intramed - ullary ﬁxation techniques, as previously discussed. - - Summary box 32.5 Diaphyseal fractures /uni25CF /uni25CF - /uni25CF
Restore length, alignment and rotation
Consider whether primary or secondary bone healing is the
objective
Radius and ulna need precise reduction to function
Diaphyseal fractures
Extra-articular fractures do not require an anatomical reduc - tion, but rather a mechanical restoration by correction of length, alignment and rotation ( Figure 32.18 ). Angular malunion of  a diaphyseal fracture of  the weight-bearing long bones will lead to abnormal joint forces on the joint above and below , leading to pain and secondary degenera tive joint disease. Diaphyseal fractures are generally well suited to intramed - ullary ﬁxation techniques, as previously discussed. - - Summary box 32.5 Diaphyseal fractures /uni25CF /uni25CF - /uni25CF
Restore length, alignment and rotation
Consider whether primary or secondary bone healing is the
objective
Radius and ulna need precise reduction to function
Diaphyseal fractures
Extra-articular fractures do not require an anatomical reduc - tion, but rather a mechanical restoration by correction of length, alignment and rotation ( Figure 32.18 ). Angular malunion of  a diaphyseal fracture of  the weight-bearing long bones will lead to abnormal joint forces on the joint above and below , leading to pain and secondary degenera tive joint disease. Diaphyseal fractures are generally well suited to intramed - ullary ﬁxation techniques, as previously discussed. - - Summary box 32.5 Diaphyseal fractures /uni25CF /uni25CF - /uni25CF
Restore length, alignment and rotation
Consider whether primary or secondary bone healing is the
objective
Radius and ulna need precise reduction to function

Distal femoral fractures
Distal femoral fractures
Metaphyseal osteoporotic fractures of  the distal femur are amenable to internal ﬁxation with locked intramedullary nails or plate and screw ﬁxation. If  the fracture extends into the articular surface, reconstruction may be undertaken with cannulated screws augmented with intramedullary nailing or injury-speciﬁc locking plates for the distal femur. More commonly now these injuries are often next to a knee replacement (periprosthetic fracture), which can add technical complexity; surgical decision making is inﬂuenced by whether the implant is attached to bone or is loose, the amount of  bone to ﬁx into and the health status of  the patient. More recently , primary and revision arthroplasty have been considered in these situations to allow early mobilisation.
Distal femoral fractures
Metaphyseal osteoporotic fractures of  the distal femur are amenable to internal ﬁxation with locked intramedullary nails or plate and screw ﬁxation. If  the fracture extends into the articular surface, reconstruction may be undertaken with cannulated screws augmented with intramedullary nailing or injury-speciﬁc locking plates for the distal femur. More commonly now these injuries are often next to a knee replacement (periprosthetic fracture), which can add technical complexity; surgical decision making is inﬂuenced by whether the implant is attached to bone or is loose, the amount of  bone to ﬁx into and the health status of  the patient. More recently , primary and revision arthroplasty have been considered in these situations to allow early mobilisation.
Distal femoral fractures
Metaphyseal osteoporotic fractures of  the distal femur are amenable to internal ﬁxation with locked intramedullary nails or plate and screw ﬁxation. If  the fracture extends into the articular surface, reconstruction may be undertaken with cannulated screws augmented with intramedullary nailing or injury-speciﬁc locking plates for the distal femur. More commonly now these injuries are often next to a knee replacement (periprosthetic fracture), which can add technical complexity; surgical decision making is inﬂuenced by whether the implant is attached to bone or is loose, the amount of  bone to ﬁx into and the health status of  the patient. More recently , primary and revision arthroplasty have been considered in these situations to allow early mobilisation.

Distal humerus (supracondylar fracture)
Distal humerus (supracondylar fracture)
Supracondylar humeral fractures are very common injuries in children. The distal humerus may go into ﬂexion or extension, extension being by far the most common. Treatment depends on the degree of  displacement. Undisplaced fractures may be protected in a collar and cu ﬀ or backslab for 3 weeks and then progressive mobilisation. If  displaced, the fracture can often be reduced with closed manipulation. If  the dorsal periosteal hinge is intact, above- elbow cast immobilisation for 3–4 weeks is often su ﬃ cient to hold the fracture until union. If the periosteal hinge is broken, percutaneous K-wires are used to hold the fracture, supplemented with an above-elbow cast.
(c)
(a)
Anteroposterior and lateral radiographs of a
(b)
The
(c)
Radiograph of
condylar fractures is V olkmann’s ischaemic contracture. This is due to excessive swelling and missed compartment syndrome in the forearm. It is particularly important not to put the elbow into deep ﬂexion if  there is a lot of  swelling. If deep ﬂexion is the only way to hold the fracture, then K-wire ﬁxation should be considered. Neurovascular injury at the time of  a supracondylar frac ture is not uncommon. Careful attention should be paid to the neurovascular status of  the limb. The white pulseless hand is a surgical emergency and requires immediate attention, assess ment and urgent reduction. If the pulse does not return with reduction, then the vessels should be explored by appropriately trained surgeons. The pink pulseless hand is more controv ersial and requires early senior decision making. If  there is satisfactory perfusion of  the limb, no suggestion of  compartment syndrome and no neurological injury , then reduction and stabilisation of the fracture is warranted and a more expectant approach to the vascular injury can be taken. Often the pulse will return within 24–48 hours. Neurological injury is common, most often a neuropraxia. They often resolve on fracture reduction, stabilisation and res olution of  the swelling. Malunion in varus or valgus remains a prob lem. Often the elbow will remodel the deformity in the anteroposterior ﬂexion–extension plane, but varus and valgus malunion remodels less. Careful attention needs to be paid to the adequacy of the reduction and K-wire placement to hold the fracture to avoid angular malunion. Distal humerus (supracondylar fracture)
Supracondylar humeral fractures are very common injuries in children. The distal humerus may go into ﬂexion or extension, extension being by far the most common. Treatment depends on the degree of  displacement. Undisplaced fractures may be protected in a collar and cu ﬀ or backslab for 3 weeks and then progressive mobilisation. If  displaced, the fracture can often be reduced with closed manipulation. If  the dorsal periosteal hinge is intact, above- elbow cast immobilisation for 3–4 weeks is often su ﬃ cient to hold the fracture until union. If the periosteal hinge is broken, percutaneous K-wires are used to hold the fracture, supplemented with an above-elbow cast.
(c)
(a)
Anteroposterior and lateral radiographs of a
(b)
The
(c)
Radiograph of
condylar fractures is V olkmann’s ischaemic contracture. This is due to excessive swelling and missed compartment syndrome in the forearm. It is particularly important not to put the elbow into deep ﬂexion if  there is a lot of  swelling. If deep ﬂexion is the only way to hold the fracture, then K-wire ﬁxation should be considered. Neurovascular injury at the time of  a supracondylar frac ture is not uncommon. Careful attention should be paid to the neurovascular status of  the limb. The white pulseless hand is a surgical emergency and requires immediate attention, assess ment and urgent reduction. If the pulse does not return with reduction, then the vessels should be explored by appropriately trained surgeons. The pink pulseless hand is more controv ersial and requires early senior decision making. If  there is satisfactory perfusion of  the limb, no suggestion of  compartment syndrome and no neurological injury , then reduction and stabilisation of the fracture is warranted and a more expectant approach to the vascular injury can be taken. Often the pulse will return within 24–48 hours. Neurological injury is common, most often a neuropraxia. They often resolve on fracture reduction, stabilisation and res olution of  the swelling. Malunion in varus or valgus remains a prob lem. Often the elbow will remodel the deformity in the anteroposterior ﬂexion–extension plane, but varus and valgus malunion remodels less. Careful attention needs to be paid to the adequacy of the reduction and K-wire placement to hold the fracture to avoid angular malunion. Distal humerus (supracondylar fracture)
Supracondylar humeral fractures are very common injuries in children. The distal humerus may go into ﬂexion or extension, extension being by far the most common. Treatment depends on the degree of  displacement. Undisplaced fractures may be protected in a collar and cu ﬀ or backslab for 3 weeks and then progressive mobilisation. If  displaced, the fracture can often be reduced with closed manipulation. If  the dorsal periosteal hinge is intact, above- elbow cast immobilisation for 3–4 weeks is often su ﬃ cient to hold the fracture until union. If the periosteal hinge is broken, percutaneous K-wires are used to hold the fracture, supplemented with an above-elbow cast.
(c)
(a)
Anteroposterior and lateral radiographs of a
(b)
The
(c)
Radiograph of
condylar fractures is V olkmann’s ischaemic contracture. This is due to excessive swelling and missed compartment syndrome in the forearm. It is particularly important not to put the elbow into deep ﬂexion if  there is a lot of  swelling. If deep ﬂexion is the only way to hold the fracture, then K-wire ﬁxation should be considered. Neurovascular injury at the time of  a supracondylar frac ture is not uncommon. Careful attention should be paid to the neurovascular status of  the limb. The white pulseless hand is a surgical emergency and requires immediate attention, assess ment and urgent reduction. If the pulse does not return with reduction, then the vessels should be explored by appropriately trained surgeons. The pink pulseless hand is more controv ersial and requires early senior decision making. If  there is satisfactory perfusion of  the limb, no suggestion of  compartment syndrome and no neurological injury , then reduction and stabilisation of the fracture is warranted and a more expectant approach to the vascular injury can be taken. Often the pulse will return within 24–48 hours. Neurological injury is common, most often a neuropraxia. They often resolve on fracture reduction, stabilisation and res olution of  the swelling. Malunion in varus or valgus remains a prob lem. Often the elbow will remodel the deformity in the anteroposterior ﬂexion–extension plane, but varus and valgus malunion remodels less. Careful attention needs to be paid to the adequacy of the reduction and K-wire placement to hold the fracture to avoid angular malunion.

Distal radial fractures
Distal radial fractures
Extra-articular (type A) fractures of the distal radius may displace in a volar or dorsal direction. It is possible to reduce volar displaced fractures (Smith’s fracture) of  the distal radius with a closed technique. However, they tend to be unstable and displace if held in a cast. Hence most volar displaced extra- articular distal radial fractures are reduced and held with a volar buttress plate ( Figure 32.23 ). Most dorsally displaced fractures (Colles fracture) can be addressed with closed reduction and held in a cast. However, Bertil Stener , 1920–1999, Swedish orthopaedic surgeon, described the anatomy and treatment of  a displaced ulna collateral ligament injury to the thumb in 1962. Robert William Smith , 1807–1873, Professor of  Surgery , Trinity College, Dublin, Ireland, described the reverse Colles fracture in 1847. Abraham Colles , 1773–1843, President of  the Royal College of  Surgeons of  Ireland (1802), Professor of  Anatomy , Physiology and Surgery (1804) and described distal radial fracture in 1814. - some will slip or collapse with cast treatment, and so close review for the ﬁrst few weeks is advocated. Fractures with signiﬁcant initial displacement and dorsal comminution are at risk of  early and late collapse. After thor - ough counselling the patient may choose to have the fracture reduced and then held surgically with K-wires, pla te and screw ﬁxation (volar or dorsal) or external ﬁxation. The K-wires may be placed acr oss the fracture fragments or intrafocally , going through the fracture site. The latter can be used to help reduce the fracture and then used to lock the fracture fragments in place ( Figure 32.24 ). Treatment is individualised based on patient and fracture pattern factors. Intra-articular fractures (types B and C) of the
(b)
(c)
(d)
Figure 32.23
An A-type or extra-articular metaphyseal fracture. A
plain lateral radiograph of this Smith-type fracture
(a, b)
. Fracture
/f_i
xed to a plate. There is no interfragmental compression. The plate is
pushing against or buttressing the distal fragment
(c, d)
.
distal radius require anatomical reduction of  the joint surface; a gap or step of  less than 2 /uni00A0 mm can be accepted in the radius. The distal radius fails fairly predictably with splitting of  the lunate fossa fragment in the coronal plane and separation of the radial styloid. If a closed reduction can be achieved with manipulation, the fracture fragments can subsequently be held with K-wires, plate and screw ﬁxation or external ﬁxation. The most common form of  treatment is closed r eduction and percutaneous K-wire ﬁxation, supplemented with a plaster cast for 4–6 weeks.
(b)
Figure 32.24 (a)
K-wires placed across fracture fragments;
(b)
/uni00A0
intrafocal K-wires used to help reduce the fracture.
Distal radial fractures
Extra-articular (type A) fractures of the distal radius may displace in a volar or dorsal direction. It is possible to reduce volar displaced fractures (Smith’s fracture) of  the distal radius with a closed technique. However, they tend to be unstable and displace if held in a cast. Hence most volar displaced extra- articular distal radial fractures are reduced and held with a volar buttress plate ( Figure 32.23 ). Most dorsally displaced fractures (Colles fracture) can be addressed with closed reduction and held in a cast. However, Bertil Stener , 1920–1999, Swedish orthopaedic surgeon, described the anatomy and treatment of  a displaced ulna collateral ligament injury to the thumb in 1962. Robert William Smith , 1807–1873, Professor of  Surgery , Trinity College, Dublin, Ireland, described the reverse Colles fracture in 1847. Abraham Colles , 1773–1843, President of  the Royal College of  Surgeons of  Ireland (1802), Professor of  Anatomy , Physiology and Surgery (1804) and described distal radial fracture in 1814. - some will slip or collapse with cast treatment, and so close review for the ﬁrst few weeks is advocated. Fractures with signiﬁcant initial displacement and dorsal comminution are at risk of  early and late collapse. After thor - ough counselling the patient may choose to have the fracture reduced and then held surgically with K-wires, pla te and screw ﬁxation (volar or dorsal) or external ﬁxation. The K-wires may be placed acr oss the fracture fragments or intrafocally , going through the fracture site. The latter can be used to help reduce the fracture and then used to lock the fracture fragments in place ( Figure 32.24 ). Treatment is individualised based on patient and fracture pattern factors. Intra-articular fractures (types B and C) of the
(b)
(c)
(d)
Figure 32.23
An A-type or extra-articular metaphyseal fracture. A
plain lateral radiograph of this Smith-type fracture
(a, b)
. Fracture
/f_i
xed to a plate. There is no interfragmental compression. The plate is
pushing against or buttressing the distal fragment
(c, d)
.
distal radius require anatomical reduction of  the joint surface; a gap or step of  less than 2 /uni00A0 mm can be accepted in the radius. The distal radius fails fairly predictably with splitting of  the lunate fossa fragment in the coronal plane and separation of the radial styloid. If a closed reduction can be achieved with manipulation, the fracture fragments can subsequently be held with K-wires, plate and screw ﬁxation or external ﬁxation. The most common form of  treatment is closed r eduction and percutaneous K-wire ﬁxation, supplemented with a plaster cast for 4–6 weeks.
(b)
Figure 32.24 (a)
K-wires placed across fracture fragments;
(b)
/uni00A0
intrafocal K-wires used to help reduce the fracture.
Distal radial fractures
Extra-articular (type A) fractures of the distal radius may displace in a volar or dorsal direction. It is possible to reduce volar displaced fractures (Smith’s fracture) of  the distal radius with a closed technique. However, they tend to be unstable and displace if held in a cast. Hence most volar displaced extra- articular distal radial fractures are reduced and held with a volar buttress plate ( Figure 32.23 ). Most dorsally displaced fractures (Colles fracture) can be addressed with closed reduction and held in a cast. However, Bertil Stener , 1920–1999, Swedish orthopaedic surgeon, described the anatomy and treatment of  a displaced ulna collateral ligament injury to the thumb in 1962. Robert William Smith , 1807–1873, Professor of  Surgery , Trinity College, Dublin, Ireland, described the reverse Colles fracture in 1847. Abraham Colles , 1773–1843, President of  the Royal College of  Surgeons of  Ireland (1802), Professor of  Anatomy , Physiology and Surgery (1804) and described distal radial fracture in 1814. - some will slip or collapse with cast treatment, and so close review for the ﬁrst few weeks is advocated. Fractures with signiﬁcant initial displacement and dorsal comminution are at risk of  early and late collapse. After thor - ough counselling the patient may choose to have the fracture reduced and then held surgically with K-wires, pla te and screw ﬁxation (volar or dorsal) or external ﬁxation. The K-wires may be placed acr oss the fracture fragments or intrafocally , going through the fracture site. The latter can be used to help reduce the fracture and then used to lock the fracture fragments in place ( Figure 32.24 ). Treatment is individualised based on patient and fracture pattern factors. Intra-articular fractures (types B and C) of the
(b)
(c)
(d)
Figure 32.23
An A-type or extra-articular metaphyseal fracture. A
plain lateral radiograph of this Smith-type fracture
(a, b)
. Fracture
/f_i
xed to a plate. There is no interfragmental compression. The plate is
pushing against or buttressing the distal fragment
(c, d)
.
distal radius require anatomical reduction of  the joint surface; a gap or step of  less than 2 /uni00A0 mm can be accepted in the radius. The distal radius fails fairly predictably with splitting of  the lunate fossa fragment in the coronal plane and separation of the radial styloid. If a closed reduction can be achieved with manipulation, the fracture fragments can subsequently be held with K-wires, plate and screw ﬁxation or external ﬁxation. The most common form of  treatment is closed r eduction and percutaneous K-wire ﬁxation, supplemented with a plaster cast for 4–6 weeks.
(b)
Figure 32.24 (a)
K-wires placed across fracture fragments;
(b)
/uni00A0
intrafocal K-wires used to help reduce the fracture.

Examination
Examination
An initial general examination, including vital signs and general assessment, should be conducted. Is this an isolated injury or do you need to start right at the beginning, considering the Achilles , the Greek hero, was the son of  Peleus and Thetis. When he was a child, his mother dipped him in the Styx, one of  the rivers of  the Underworld so that he should be invulnerable in battle. The heel by which she held him did not get wet, and was, therefore, not protected. Achilles died from a wound in the heel received at the siege of  Troy . individual extremity only begins once you are sure the patient is stable and life- and limb-threatening conditions have been excluded. It is crucial to undertake a thorough top-to-toe evaluation in the secondary survey . Often the minor extremity injuries - are missed ( Figur e 32.1 ) and can cause signiﬁcant long-term problems ( Table 32.1 ). A top-to-toe evaluation is achieved by a systematic approach (see Chapter 35 and Apley’s system of orthopaedics and fractures [Further reading] ) to the injured extremity: /uni25CF look; /uni25CF feel; /uni25CF move (active and passive); /uni25CF special tests; /uni25CF special investigations. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Ensure you examine the joint above and the joint below the site of  injury . Consider the events and mechanism of  injury and examine the areas that could possibly be a ﬀ ected. For example, a patient who falls from a height may fracture the calcaneus, which is an obvious diagnosis with a very swollen hindfoot and extremely tender heel. The concomitant lumbar spine fracture may not become evident until a few days later when the distracting pain in the heel starts to subside. Look It is important to look at the whole limb, back and front, noting any localised swelling, bruising and any obvious deformity . A shortened externally rotated leg in an older patient suggests a fracture of  the proximal femur. A slightly ﬂexed, adducted internally rotated leg might suggest a posterior dislocation of the hip. Any break in the skin or abrasion needs to be noted and the treating orthopaedic surgeon informed, even if  you do not think it communicates with the fracture. A graze over the knee in a closed tibial fractur e may preclude intramedullary nail - ing until the wound has healed over, or perhaps an alternative treatment may have to be considered. Ideally a photograph (with appropriate consent) should be taken to document the injury and obviate the need for repeated manipulation of the dressings (see Open fractures ).
(a)
(b)
Figure 32.1
(a)
Missed dislocation of the metatarsophalangeal joint of
the little toe, picked up at 8 weeks.
(b)
Initial trauma computed tomog
raphy angiogram. In retrospect, on close inspection the dislocation is
visible on the angiogram; do not be distracted by the obvious femoral
shaft fracture.
TABLE 32.1
Extremity injuries that are notorious for being
missed.
Posterior dislocation of the shoulder
Lateral condylar mass fracture of the distal humerus
Perilunate dislocation
Scaphoid fracture
Tarsometatarsal fracture dislocation
Compartment syndrome
Vascular injury with knee dislocation
Talar neck fracture
Slipped upper femoral epiphysis
Achilles tendon rupture
ing. A compartment syndrome may still be present even when a limb does not appear to be very swollen (see Compartment syndrome ), but if it is grossly swollen, note, document and pass on the information. Look for pre-existing scars; a scar at the back of  the elbow or over the cubital tunnel might signify an anterior transposi tion of  the ulnar nerve. Scars might signify previous metalwork that remains in situ or has been removed in the past. Feel Start gently examining the limb away from the zone of obvi ous injury , gaining the patient’s trust and gathering as much information as possible beforehand, and without causing the patient pain or discomfort. Feel for bony tenderness and note the degree of  swelling and tenseness of  the compartments should be noted that it is not possible to exclude a compart ment syndrome based on how tense the limb feels. The deep posterior compartment of  the lower leg cannot be felt when palpating the skin. The characteristic crepitus of  subcutaneous air can be felt in the setting of  open fractures, air-jet injuries and around the chest in the presence of a pneumothorax. The examiner should feel for pulses and assess capillary return (see Neurovascular examination ) as w ell as feeling for temperature changes. Move Movement as part of  the examination should once again be approached carefully and without causing the patient pain and discomfort. Two types of  movement can be assessed: 1 active – active movement is movement initiated and main tained by the patient; 2 passive – passive movement is when the examiner moves the limb. Special tests There are often special tests to detect injury in precise anatom ical locations and many are described elsewhere in the book; for example, looking for a ruptured Achilles tendon by placing the patient prone with the foot over the edge of  the bed and squeezing the calf; plantarﬂexion of  the foot and ankle then suggests the Ac hilles tendon is intact. The examiner should be aware of  gravity simulating active movements. For example, a leg lying ﬂat, fully extended on the couch does not mean the extensor mechanism of  the knee is intact. In all knee injuries make sure the patient can actively straight leg raise and get their leg o ﬀ the couch. Similar pitfalls exist in the upper limb with gravity straight ening the elbow . In order to assess triceps function and elbow extension, ensure that the patient can actively extend against resistance from the e xaminer or against gravity . Beware of  trick movements. Patients with a complete rup ture of  the quadriceps can still walk with the leg locked in full to slight hyperextension by using the iliotibial band. Patients with complete rupture of  the Achilles tendon can still actively plantar ﬂex the foot and ankle using the long toe ﬂexors. This is an important part of  extremity examination and summary terms such as ‘neurovascularly intact’ are best avoided. It is preferable to clearly document the examination performed and its ﬁndings, along with a conclusion about the function of  the particular neurological or vascular anatomy - tested. On occasion you may not be able to examine all move - ments because of  injury or casts. It is important to examine and document ﬁndings before and after any manipulation or cast application to ensure no change. A radial nerve palsy in association with a humeral shaft fracture that occurs at the time of  injury may be treated e xpec - - tantly . If, however, radial nerve function is lost after application of  a cast or brace, the nerve should be explored. Most periph - eral nerves have a motor and sensory component; document both sensibility and motor function. . It Laceration or rupture of  major vessels may result in life- - and limb-thr eatening injury and should be dealt with as an emergency (see ATLS principles discussed in Chapter 27 ). Complete laceration or occlusion of  a major vessel is obvious and seldom missed. In contrast, occult vessel injuries must be considered and actively excluded. In 30% of  knee disloca tions (tibiofemoral dislocation) a vascular injury will occur ( Figure 32.2 ). The presence of palpable pulses does not exclude a signiﬁ - cant vascular injury and an intimal ﬂap may develop, progress and thrombose over time. Repeated evaluation is necessary , before and after any intervention, f or example a manipulation or cast application. In injuries commonly associated with vascular injury , such as knee dislocations, occult injury should be actively excluded with an angiogram. If  an angiogram is not performed, repeated thorough vascular evaluation of the limb should be undertaken - for the ﬁrst 24–48 hours. Open fractures also demand attention to the neurological and vascular status of  the limb. In the more severe injuries, there may be both neurological and vascular injury requiring immediate surgical attention through rapid spanning of  the limb, creation of  an arterial shunt to provide urgent inﬂow - and subsequent vascular grafting. Once ﬂow has been restored, usually at the same or another surgical sitting, the fracture can then be stabilised deﬁnitively with appropriate soft-tissue cover. Performing the arterial shunt before temporary stability has been achieved can compromise the later arterial reconstruc - tion as length, rotation and alignment would not have been restored, thereby pulling on the graft. Open fractures require multiple specialty input. Examination
An initial general examination, including vital signs and general assessment, should be conducted. Is this an isolated injury or do you need to start right at the beginning, considering the Achilles , the Greek hero, was the son of  Peleus and Thetis. When he was a child, his mother dipped him in the Styx, one of  the rivers of  the Underworld so that he should be invulnerable in battle. The heel by which she held him did not get wet, and was, therefore, not protected. Achilles died from a wound in the heel received at the siege of  Troy . individual extremity only begins once you are sure the patient is stable and life- and limb-threatening conditions have been excluded. It is crucial to undertake a thorough top-to-toe evaluation in the secondary survey . Often the minor extremity injuries - are missed ( Figur e 32.1 ) and can cause signiﬁcant long-term problems ( Table 32.1 ). A top-to-toe evaluation is achieved by a systematic approach (see Chapter 35 and Apley’s system of orthopaedics and fractures [Further reading] ) to the injured extremity: /uni25CF look; /uni25CF feel; /uni25CF move (active and passive); /uni25CF special tests; /uni25CF special investigations. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Ensure you examine the joint above and the joint below the site of  injury . Consider the events and mechanism of  injury and examine the areas that could possibly be a ﬀ ected. For example, a patient who falls from a height may fracture the calcaneus, which is an obvious diagnosis with a very swollen hindfoot and extremely tender heel. The concomitant lumbar spine fracture may not become evident until a few days later when the distracting pain in the heel starts to subside. Look It is important to look at the whole limb, back and front, noting any localised swelling, bruising and any obvious deformity . A shortened externally rotated leg in an older patient suggests a fracture of  the proximal femur. A slightly ﬂexed, adducted internally rotated leg might suggest a posterior dislocation of the hip. Any break in the skin or abrasion needs to be noted and the treating orthopaedic surgeon informed, even if  you do not think it communicates with the fracture. A graze over the knee in a closed tibial fractur e may preclude intramedullary nail - ing until the wound has healed over, or perhaps an alternative treatment may have to be considered. Ideally a photograph (with appropriate consent) should be taken to document the injury and obviate the need for repeated manipulation of the dressings (see Open fractures ).
(a)
(b)
Figure 32.1
(a)
Missed dislocation of the metatarsophalangeal joint of
the little toe, picked up at 8 weeks.
(b)
Initial trauma computed tomog
raphy angiogram. In retrospect, on close inspection the dislocation is
visible on the angiogram; do not be distracted by the obvious femoral
shaft fracture.
TABLE 32.1
Extremity injuries that are notorious for being
missed.
Posterior dislocation of the shoulder
Lateral condylar mass fracture of the distal humerus
Perilunate dislocation
Scaphoid fracture
Tarsometatarsal fracture dislocation
Compartment syndrome
Vascular injury with knee dislocation
Talar neck fracture
Slipped upper femoral epiphysis
Achilles tendon rupture
ing. A compartment syndrome may still be present even when a limb does not appear to be very swollen (see Compartment syndrome ), but if it is grossly swollen, note, document and pass on the information. Look for pre-existing scars; a scar at the back of  the elbow or over the cubital tunnel might signify an anterior transposi tion of  the ulnar nerve. Scars might signify previous metalwork that remains in situ or has been removed in the past. Feel Start gently examining the limb away from the zone of obvi ous injury , gaining the patient’s trust and gathering as much information as possible beforehand, and without causing the patient pain or discomfort. Feel for bony tenderness and note the degree of  swelling and tenseness of  the compartments should be noted that it is not possible to exclude a compart ment syndrome based on how tense the limb feels. The deep posterior compartment of  the lower leg cannot be felt when palpating the skin. The characteristic crepitus of  subcutaneous air can be felt in the setting of  open fractures, air-jet injuries and around the chest in the presence of a pneumothorax. The examiner should feel for pulses and assess capillary return (see Neurovascular examination ) as w ell as feeling for temperature changes. Move Movement as part of  the examination should once again be approached carefully and without causing the patient pain and discomfort. Two types of  movement can be assessed: 1 active – active movement is movement initiated and main tained by the patient; 2 passive – passive movement is when the examiner moves the limb. Special tests There are often special tests to detect injury in precise anatom ical locations and many are described elsewhere in the book; for example, looking for a ruptured Achilles tendon by placing the patient prone with the foot over the edge of  the bed and squeezing the calf; plantarﬂexion of  the foot and ankle then suggests the Ac hilles tendon is intact. The examiner should be aware of  gravity simulating active movements. For example, a leg lying ﬂat, fully extended on the couch does not mean the extensor mechanism of  the knee is intact. In all knee injuries make sure the patient can actively straight leg raise and get their leg o ﬀ the couch. Similar pitfalls exist in the upper limb with gravity straight ening the elbow . In order to assess triceps function and elbow extension, ensure that the patient can actively extend against resistance from the e xaminer or against gravity . Beware of  trick movements. Patients with a complete rup ture of  the quadriceps can still walk with the leg locked in full to slight hyperextension by using the iliotibial band. Patients with complete rupture of  the Achilles tendon can still actively plantar ﬂex the foot and ankle using the long toe ﬂexors. This is an important part of  extremity examination and summary terms such as ‘neurovascularly intact’ are best avoided. It is preferable to clearly document the examination performed and its ﬁndings, along with a conclusion about the function of  the particular neurological or vascular anatomy - tested. On occasion you may not be able to examine all move - ments because of  injury or casts. It is important to examine and document ﬁndings before and after any manipulation or cast application to ensure no change. A radial nerve palsy in association with a humeral shaft fracture that occurs at the time of  injury may be treated e xpec - - tantly . If, however, radial nerve function is lost after application of  a cast or brace, the nerve should be explored. Most periph - eral nerves have a motor and sensory component; document both sensibility and motor function. . It Laceration or rupture of  major vessels may result in life- - and limb-thr eatening injury and should be dealt with as an emergency (see ATLS principles discussed in Chapter 27 ). Complete laceration or occlusion of  a major vessel is obvious and seldom missed. In contrast, occult vessel injuries must be considered and actively excluded. In 30% of  knee disloca tions (tibiofemoral dislocation) a vascular injury will occur ( Figure 32.2 ). The presence of palpable pulses does not exclude a signiﬁ - cant vascular injury and an intimal ﬂap may develop, progress and thrombose over time. Repeated evaluation is necessary , before and after any intervention, f or example a manipulation or cast application. In injuries commonly associated with vascular injury , such as knee dislocations, occult injury should be actively excluded with an angiogram. If  an angiogram is not performed, repeated thorough vascular evaluation of the limb should be undertaken - for the ﬁrst 24–48 hours. Open fractures also demand attention to the neurological and vascular status of  the limb. In the more severe injuries, there may be both neurological and vascular injury requiring immediate surgical attention through rapid spanning of  the limb, creation of  an arterial shunt to provide urgent inﬂow - and subsequent vascular grafting. Once ﬂow has been restored, usually at the same or another surgical sitting, the fracture can then be stabilised deﬁnitively with appropriate soft-tissue cover. Performing the arterial shunt before temporary stability has been achieved can compromise the later arterial reconstruc - tion as length, rotation and alignment would not have been restored, thereby pulling on the graft. Open fractures require multiple specialty input. Examination
An initial general examination, including vital signs and general assessment, should be conducted. Is this an isolated injury or do you need to start right at the beginning, considering the Achilles , the Greek hero, was the son of  Peleus and Thetis. When he was a child, his mother dipped him in the Styx, one of  the rivers of  the Underworld so that he should be invulnerable in battle. The heel by which she held him did not get wet, and was, therefore, not protected. Achilles died from a wound in the heel received at the siege of  Troy . individual extremity only begins once you are sure the patient is stable and life- and limb-threatening conditions have been excluded. It is crucial to undertake a thorough top-to-toe evaluation in the secondary survey . Often the minor extremity injuries - are missed ( Figur e 32.1 ) and can cause signiﬁcant long-term problems ( Table 32.1 ). A top-to-toe evaluation is achieved by a systematic approach (see Chapter 35 and Apley’s system of orthopaedics and fractures [Further reading] ) to the injured extremity: /uni25CF look; /uni25CF feel; /uni25CF move (active and passive); /uni25CF special tests; /uni25CF special investigations. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Ensure you examine the joint above and the joint below the site of  injury . Consider the events and mechanism of  injury and examine the areas that could possibly be a ﬀ ected. For example, a patient who falls from a height may fracture the calcaneus, which is an obvious diagnosis with a very swollen hindfoot and extremely tender heel. The concomitant lumbar spine fracture may not become evident until a few days later when the distracting pain in the heel starts to subside. Look It is important to look at the whole limb, back and front, noting any localised swelling, bruising and any obvious deformity . A shortened externally rotated leg in an older patient suggests a fracture of  the proximal femur. A slightly ﬂexed, adducted internally rotated leg might suggest a posterior dislocation of the hip. Any break in the skin or abrasion needs to be noted and the treating orthopaedic surgeon informed, even if  you do not think it communicates with the fracture. A graze over the knee in a closed tibial fractur e may preclude intramedullary nail - ing until the wound has healed over, or perhaps an alternative treatment may have to be considered. Ideally a photograph (with appropriate consent) should be taken to document the injury and obviate the need for repeated manipulation of the dressings (see Open fractures ).
(a)
(b)
Figure 32.1
(a)
Missed dislocation of the metatarsophalangeal joint of
the little toe, picked up at 8 weeks.
(b)
Initial trauma computed tomog
raphy angiogram. In retrospect, on close inspection the dislocation is
visible on the angiogram; do not be distracted by the obvious femoral
shaft fracture.
TABLE 32.1
Extremity injuries that are notorious for being
missed.
Posterior dislocation of the shoulder
Lateral condylar mass fracture of the distal humerus
Perilunate dislocation
Scaphoid fracture
Tarsometatarsal fracture dislocation
Compartment syndrome
Vascular injury with knee dislocation
Talar neck fracture
Slipped upper femoral epiphysis
Achilles tendon rupture
ing. A compartment syndrome may still be present even when a limb does not appear to be very swollen (see Compartment syndrome ), but if it is grossly swollen, note, document and pass on the information. Look for pre-existing scars; a scar at the back of  the elbow or over the cubital tunnel might signify an anterior transposi tion of  the ulnar nerve. Scars might signify previous metalwork that remains in situ or has been removed in the past. Feel Start gently examining the limb away from the zone of obvi ous injury , gaining the patient’s trust and gathering as much information as possible beforehand, and without causing the patient pain or discomfort. Feel for bony tenderness and note the degree of  swelling and tenseness of  the compartments should be noted that it is not possible to exclude a compart ment syndrome based on how tense the limb feels. The deep posterior compartment of  the lower leg cannot be felt when palpating the skin. The characteristic crepitus of  subcutaneous air can be felt in the setting of  open fractures, air-jet injuries and around the chest in the presence of a pneumothorax. The examiner should feel for pulses and assess capillary return (see Neurovascular examination ) as w ell as feeling for temperature changes. Move Movement as part of  the examination should once again be approached carefully and without causing the patient pain and discomfort. Two types of  movement can be assessed: 1 active – active movement is movement initiated and main tained by the patient; 2 passive – passive movement is when the examiner moves the limb. Special tests There are often special tests to detect injury in precise anatom ical locations and many are described elsewhere in the book; for example, looking for a ruptured Achilles tendon by placing the patient prone with the foot over the edge of  the bed and squeezing the calf; plantarﬂexion of  the foot and ankle then suggests the Ac hilles tendon is intact. The examiner should be aware of  gravity simulating active movements. For example, a leg lying ﬂat, fully extended on the couch does not mean the extensor mechanism of  the knee is intact. In all knee injuries make sure the patient can actively straight leg raise and get their leg o ﬀ the couch. Similar pitfalls exist in the upper limb with gravity straight ening the elbow . In order to assess triceps function and elbow extension, ensure that the patient can actively extend against resistance from the e xaminer or against gravity . Beware of  trick movements. Patients with a complete rup ture of  the quadriceps can still walk with the leg locked in full to slight hyperextension by using the iliotibial band. Patients with complete rupture of  the Achilles tendon can still actively plantar ﬂex the foot and ankle using the long toe ﬂexors. This is an important part of  extremity examination and summary terms such as ‘neurovascularly intact’ are best avoided. It is preferable to clearly document the examination performed and its ﬁndings, along with a conclusion about the function of  the particular neurological or vascular anatomy - tested. On occasion you may not be able to examine all move - ments because of  injury or casts. It is important to examine and document ﬁndings before and after any manipulation or cast application to ensure no change. A radial nerve palsy in association with a humeral shaft fracture that occurs at the time of  injury may be treated e xpec - - tantly . If, however, radial nerve function is lost after application of  a cast or brace, the nerve should be explored. Most periph - eral nerves have a motor and sensory component; document both sensibility and motor function. . It Laceration or rupture of  major vessels may result in life- - and limb-thr eatening injury and should be dealt with as an emergency (see ATLS principles discussed in Chapter 27 ). Complete laceration or occlusion of  a major vessel is obvious and seldom missed. In contrast, occult vessel injuries must be considered and actively excluded. In 30% of  knee disloca tions (tibiofemoral dislocation) a vascular injury will occur ( Figure 32.2 ). The presence of palpable pulses does not exclude a signiﬁ - cant vascular injury and an intimal ﬂap may develop, progress and thrombose over time. Repeated evaluation is necessary , before and after any intervention, f or example a manipulation or cast application. In injuries commonly associated with vascular injury , such as knee dislocations, occult injury should be actively excluded with an angiogram. If  an angiogram is not performed, repeated thorough vascular evaluation of the limb should be undertaken - for the ﬁrst 24–48 hours. Open fractures also demand attention to the neurological and vascular status of  the limb. In the more severe injuries, there may be both neurological and vascular injury requiring immediate surgical attention through rapid spanning of  the limb, creation of  an arterial shunt to provide urgent inﬂow - and subsequent vascular grafting. Once ﬂow has been restored, usually at the same or another surgical sitting, the fracture can then be stabilised deﬁnitively with appropriate soft-tissue cover. Performing the arterial shunt before temporary stability has been achieved can compromise the later arterial reconstruc - tion as length, rotation and alignment would not have been restored, thereby pulling on the graft. Open fractures require multiple specialty input.

FRACTURE HEALING
FRACTURE HEALING
It is useful to review fracture healing, as it relates to treatment and outcome. Following a fracture, bone can heal in two di ﬀ er - ent ways: direct (primary) bone healing or indirect (secondary) bone healing. One can conceptualise direct bone healing as being akin to a wound that is stitched together whereas indirect bone healing is similar to forming a scab that over time turns ): to nor mal tissue. Through intervention, the clinician is able - to inﬂuence the healing response of  the tissue: direct bone healing being more likely if  the two bone ends are squeezed together (compression), and indirect healing should there be - movement (termed strain) at the fracture site. If  there is too much movement, i.e. the fracture is too unstable, healing of the fracture may not occur. /uni25CF Direct bone healing , as the name implies, heals directly with bone and without callus formation. It happens in an - environment of  cortical apposition and absolute stability with no movement or gap between the fracture fragments. - directed across the fracture interface. Osteoclastic cutting cones cut across the fracture line, with following osteoblasts laying down lamellar bone across the fracture. This is sim ilar to the normal remodelling process that occurs in bone all the time as part of  skeletal homeostasis. /uni25CF Indirect bone healing involves a transition from one tissue to another with callus formation. It is the most common form of  bone healing. Following the injury , haematoma ﬁlls the gap at the fracture site. In response to a varying strain and under the inﬂuence of  bone- stimulating factors, the tissue undergoes di ﬀ erentiation, from haematoma to ﬁbrous tissue and then to soft callus, followed by mineralisation and formation of  mature bone. The amount of  strain determines the nature of  tissue it di ﬀ erentiates into: under 100% leads to ﬁbrous tissue, under 10% soft callus, less than 2% hard callus and progressive mineralisation (Perren’s theory of  bone healing). Hence a little movement is good, too much movement is bad. Bone healing requires not only an advantageous mechan ical environment but also an advantageous biological envi ronment. Principally this can be described in terms of  blood supply and the preservation of  blood supply from the sur rounding soft tissues, the periosteum and the nutrient arterial supply to bone. Should the inﬂow be a ﬀ ected through trauma or peripheral vascular disease, or should there be an extensive soft-tissue injur y causing poor bone perfusion, bone healing can be a ﬀ ected. Similarly , microscopic inﬂow issues at the tis sue perfusion level, e.g. as a result of  diabetes, may also lead to poor bone healing. Infection may also create a biological insult to bone healing; therefore, open fractures with their extensive soft-tissue injury and increased probability of  infection are prone to impair ed bone healing. FRACTURE HEALING
It is useful to review fracture healing, as it relates to treatment and outcome. Following a fracture, bone can heal in two di ﬀ er - ent ways: direct (primary) bone healing or indirect (secondary) bone healing. One can conceptualise direct bone healing as being akin to a wound that is stitched together whereas indirect bone healing is similar to forming a scab that over time turns ): to nor mal tissue. Through intervention, the clinician is able - to inﬂuence the healing response of  the tissue: direct bone healing being more likely if  the two bone ends are squeezed together (compression), and indirect healing should there be - movement (termed strain) at the fracture site. If  there is too much movement, i.e. the fracture is too unstable, healing of the fracture may not occur. /uni25CF Direct bone healing , as the name implies, heals directly with bone and without callus formation. It happens in an - environment of  cortical apposition and absolute stability with no movement or gap between the fracture fragments. - directed across the fracture interface. Osteoclastic cutting cones cut across the fracture line, with following osteoblasts laying down lamellar bone across the fracture. This is sim ilar to the normal remodelling process that occurs in bone all the time as part of  skeletal homeostasis. /uni25CF Indirect bone healing involves a transition from one tissue to another with callus formation. It is the most common form of  bone healing. Following the injury , haematoma ﬁlls the gap at the fracture site. In response to a varying strain and under the inﬂuence of  bone- stimulating factors, the tissue undergoes di ﬀ erentiation, from haematoma to ﬁbrous tissue and then to soft callus, followed by mineralisation and formation of  mature bone. The amount of  strain determines the nature of  tissue it di ﬀ erentiates into: under 100% leads to ﬁbrous tissue, under 10% soft callus, less than 2% hard callus and progressive mineralisation (Perren’s theory of  bone healing). Hence a little movement is good, too much movement is bad. Bone healing requires not only an advantageous mechan ical environment but also an advantageous biological envi ronment. Principally this can be described in terms of  blood supply and the preservation of  blood supply from the sur rounding soft tissues, the periosteum and the nutrient arterial supply to bone. Should the inﬂow be a ﬀ ected through trauma or peripheral vascular disease, or should there be an extensive soft-tissue injur y causing poor bone perfusion, bone healing can be a ﬀ ected. Similarly , microscopic inﬂow issues at the tis sue perfusion level, e.g. as a result of  diabetes, may also lead to poor bone healing. Infection may also create a biological insult to bone healing; therefore, open fractures with their extensive soft-tissue injury and increased probability of  infection are prone to impair ed bone healing. FRACTURE HEALING
It is useful to review fracture healing, as it relates to treatment and outcome. Following a fracture, bone can heal in two di ﬀ er - ent ways: direct (primary) bone healing or indirect (secondary) bone healing. One can conceptualise direct bone healing as being akin to a wound that is stitched together whereas indirect bone healing is similar to forming a scab that over time turns ): to nor mal tissue. Through intervention, the clinician is able - to inﬂuence the healing response of  the tissue: direct bone healing being more likely if  the two bone ends are squeezed together (compression), and indirect healing should there be - movement (termed strain) at the fracture site. If  there is too much movement, i.e. the fracture is too unstable, healing of the fracture may not occur. /uni25CF Direct bone healing , as the name implies, heals directly with bone and without callus formation. It happens in an - environment of  cortical apposition and absolute stability with no movement or gap between the fracture fragments. - directed across the fracture interface. Osteoclastic cutting cones cut across the fracture line, with following osteoblasts laying down lamellar bone across the fracture. This is sim ilar to the normal remodelling process that occurs in bone all the time as part of  skeletal homeostasis. /uni25CF Indirect bone healing involves a transition from one tissue to another with callus formation. It is the most common form of  bone healing. Following the injury , haematoma ﬁlls the gap at the fracture site. In response to a varying strain and under the inﬂuence of  bone- stimulating factors, the tissue undergoes di ﬀ erentiation, from haematoma to ﬁbrous tissue and then to soft callus, followed by mineralisation and formation of  mature bone. The amount of  strain determines the nature of  tissue it di ﬀ erentiates into: under 100% leads to ﬁbrous tissue, under 10% soft callus, less than 2% hard callus and progressive mineralisation (Perren’s theory of  bone healing). Hence a little movement is good, too much movement is bad. Bone healing requires not only an advantageous mechan ical environment but also an advantageous biological envi ronment. Principally this can be described in terms of  blood supply and the preservation of  blood supply from the sur rounding soft tissues, the periosteum and the nutrient arterial supply to bone. Should the inﬂow be a ﬀ ected through trauma or peripheral vascular disease, or should there be an extensive soft-tissue injur y causing poor bone perfusion, bone healing can be a ﬀ ected. Similarly , microscopic inﬂow issues at the tis sue perfusion level, e.g. as a result of  diabetes, may also lead to poor bone healing. Infection may also create a biological insult to bone healing; therefore, open fractures with their extensive soft-tissue injury and increased probability of  infection are prone to impair ed bone healing.

FURTHER READING
FURTHER READING
Blom A, Warwick D, Whitehouse M. Apley’s system of  orthopaedics and fractures , 10th edn. Boca Raton, FL: CRC Press, 2017. Bone LR, Johnson KD, Weight J, Scheinberg RJ. Early versus delayed stabilization of  femoral fractures. J Bone Joint Surg 1989; 33640. British Orthopaedic Association. BOA standards for trauma and orthopaedics (BOAST s) . Available from https://www .boa.ac.uk/ standards-guidance/boasts.html (accessed 31 March 2022). Livingstone, 1950. Gustilo RB, Anderson JT . Prevention of infection in the treatment of 1025 open fractures of  long bones. J Bone Joint Surg 1976; 8A : 453–8. Mast J, Jakob R, Ganz R. Planning and reduction technique in fracture surgery . Berlin: Springer-V erlag, 1989. Medicines and Healthcare products Regulatory Agency . Guidance: Magnetic resonance imaging equipment in clinical use: safety guidelines . London: MHRA, 2014. Available from https://www .gov .uk/ government/publications/safety-guidelines-for-magnetic-resonance - imaging-equipment-in-clinical-use Muller ME, Nazarian S, Koch P . The AO classiﬁcation of  fractures . Schatzker J (trans). Berlin: Springer-V erlag, 1988. Rajasekaran S, Sabapathy SR, Dheenadhayalan J et al . Ganga hospital open injury score in management of  open injuries. Eur J Trauma Emerg Surg 2015; 41(1) : 3-15. Tornetta P , Ricci W , Court-Brown CM et al . (eds). Rockwood and Green’s 71A : fractures in adults , 9th edn. Philadelphia, PA: Wolters Kluwer, 2019. Tscherne H, Oestern HJ. Die Klassiﬁzierung des Weichteilschadens bei o ﬀ enen und geschlossenen Frakturen (A new classiﬁcation of soft-tissue damage in open and closed fractures [author’s transl]). Unfallheilkunde 1982; 85(3) : 111–15. German. FURTHER READING
Blom A, Warwick D, Whitehouse M. Apley’s system of  orthopaedics and fractures , 10th edn. Boca Raton, FL: CRC Press, 2017. Bone LR, Johnson KD, Weight J, Scheinberg RJ. Early versus delayed stabilization of  femoral fractures. J Bone Joint Surg 1989; 33640. British Orthopaedic Association. BOA standards for trauma and orthopaedics (BOAST s) . Available from https://www .boa.ac.uk/ standards-guidance/boasts.html (accessed 31 March 2022). Livingstone, 1950. Gustilo RB, Anderson JT . Prevention of infection in the treatment of 1025 open fractures of  long bones. J Bone Joint Surg 1976; 8A : 453–8. Mast J, Jakob R, Ganz R. Planning and reduction technique in fracture surgery . Berlin: Springer-V erlag, 1989. Medicines and Healthcare products Regulatory Agency . Guidance: Magnetic resonance imaging equipment in clinical use: safety guidelines . London: MHRA, 2014. Available from https://www .gov .uk/ government/publications/safety-guidelines-for-magnetic-resonance - imaging-equipment-in-clinical-use Muller ME, Nazarian S, Koch P . The AO classiﬁcation of  fractures . Schatzker J (trans). Berlin: Springer-V erlag, 1988. Rajasekaran S, Sabapathy SR, Dheenadhayalan J et al . Ganga hospital open injury score in management of  open injuries. Eur J Trauma Emerg Surg 2015; 41(1) : 3-15. Tornetta P , Ricci W , Court-Brown CM et al . (eds). Rockwood and Green’s 71A : fractures in adults , 9th edn. Philadelphia, PA: Wolters Kluwer, 2019. Tscherne H, Oestern HJ. Die Klassiﬁzierung des Weichteilschadens bei o ﬀ enen und geschlossenen Frakturen (A new classiﬁcation of soft-tissue damage in open and closed fractures [author’s transl]). Unfallheilkunde 1982; 85(3) : 111–15. German. FURTHER READING
Blom A, Warwick D, Whitehouse M. Apley’s system of  orthopaedics and fractures , 10th edn. Boca Raton, FL: CRC Press, 2017. Bone LR, Johnson KD, Weight J, Scheinberg RJ. Early versus delayed stabilization of  femoral fractures. J Bone Joint Surg 1989; 33640. British Orthopaedic Association. BOA standards for trauma and orthopaedics (BOAST s) . Available from https://www .boa.ac.uk/ standards-guidance/boasts.html (accessed 31 March 2022). Livingstone, 1950. Gustilo RB, Anderson JT . Prevention of infection in the treatment of 1025 open fractures of  long bones. J Bone Joint Surg 1976; 8A : 453–8. Mast J, Jakob R, Ganz R. Planning and reduction technique in fracture surgery . Berlin: Springer-V erlag, 1989. Medicines and Healthcare products Regulatory Agency . Guidance: Magnetic resonance imaging equipment in clinical use: safety guidelines . London: MHRA, 2014. Available from https://www .gov .uk/ government/publications/safety-guidelines-for-magnetic-resonance - imaging-equipment-in-clinical-use Muller ME, Nazarian S, Koch P . The AO classiﬁcation of  fractures . Schatzker J (trans). Berlin: Springer-V erlag, 1988. Rajasekaran S, Sabapathy SR, Dheenadhayalan J et al . Ganga hospital open injury score in management of  open injuries. Eur J Trauma Emerg Surg 2015; 41(1) : 3-15. Tornetta P , Ricci W , Court-Brown CM et al . (eds). Rockwood and Green’s 71A : fractures in adults , 9th edn. Philadelphia, PA: Wolters Kluwer, 2019. Tscherne H, Oestern HJ. Die Klassiﬁzierung des Weichteilschadens bei o ﬀ enen und geschlossenen Frakturen (A new classiﬁcation of soft-tissue damage in open and closed fractures [author’s transl]). Unfallheilkunde 1982; 85(3) : 111–15. German.

Femoral shaft fractures
Femoral shaft fractures
It is possible to treat diaphyseal fractures of  the femoral shaft non-operatively . The fracture can be reduced and held in position until union with traction; however, it takes 3 months. This is a long time to be in hospital and carries all the potential risks of  prolonged bed rest. Most femoral shaft fractures are treated with a locked intramedullary nail. With modern locked intramedullary implants, the patient will be up and out of  bed the following day and, if  it is an depends on the fracture pattern and implant used. If  there is a simple fracture pa ttern with cortical apposition, it will be possible to mobilise with crutches, weight-bearing as comfort allows. Although it may still take 3 months or more f or the fracture to unite, the implant will be able to carry the load until union, allowing earlier return to function out of  the hospital. Femoral shaft fractures
Femoral shaft fractures in children are treated based on the age and size of  the child: /uni25CF infants (0–18 months); /uni25CF toddlers and small children (18 months–4 years); - /uni25CF children (4–12 years); /uni25CF older children/adolescents.
(b)
In infants (0–18 months), ensure that there is no evidence of non-accidental injury . In infants under 12–15 /uni00A0 kg, gallows traction is acceptable. This traction involves suspension of  the legs vertically with the buttocks just o ﬀ the bed. In toddlers and small children treatment is by traction initially followed by hip spica application. Shortening of  up to 1 /uni00A0 cm and angulation of  15–20° can be accepted depending on the age of  the child because of  extensive remodelling potential. As the child gets older and time to union increases, the non-operative measures of traction and hip spica become more cumbersome. In children from 4 to 12 years se veral treatment options exist: traction and hip spica, elastic stable intramedullary nailing (ESIN), external ﬁxation or plate ﬁxation. Deﬁnitive trea tment depends on surgeon skills, facilities and patient and parent needs. In older children and adolescents, non-operative treatment with traction and hip spica cast application becomes less toler able. Depending on the size and build of  the patient, operative treatment may include ESIN ( Figure 32.31 ), exter nal ﬁxation Augusto Sarmiento , b. 1927, Colombian orthopaedic surgeon, Professor and Chairman of  the Department of  Orthopedics, University of  Southern California, Los Angeles, CA, USA. or plate ﬁxation. In larger overweight adolescents, titanium elastic nails may not be strong enough to resist bending forces and locked intramedullary nailing may be considered. Summary box 32.6 Fractures in the skeletally immature /uni25CF /uni25CF /uni25CF /uni25CF It is important, however, to remember that there is a small chance of  avascular necrosis of  the femoral head if  an ante - grade intramedullary nail is used prior to or just after physeal closure. This is a rare but devastating complication in this age group. Far lateral entry point nails on the greater trochanter have been developed to limit the e ﬀ ect on the blood supply to the femoral head; however, the risk of  avascular necrosis persists.
(b)
Figure 32.30
Slipped left upper femoral epiphysis.
(a)
Plain radio
graph;
(b)
the injury highlighted.
Figure 32.31
(a–c)
Femoral shaft fracture in a child that has been
stabilised with elastic nails.
Do not forget non-accidental injury
Be reluctant to remanipulate a physeal injury
Elastic nails are a signi
/f_i
cant step forward in fracture treatment
in children
Not many fractures require operative intervention in children
Femoral shaft fractures
It is possible to treat diaphyseal fractures of  the femoral shaft non-operatively . The fracture can be reduced and held in position until union with traction; however, it takes 3 months. This is a long time to be in hospital and carries all the potential risks of  prolonged bed rest. Most femoral shaft fractures are treated with a locked intramedullary nail. With modern locked intramedullary implants, the patient will be up and out of  bed the following day and, if  it is an depends on the fracture pattern and implant used. If  there is a simple fracture pa ttern with cortical apposition, it will be possible to mobilise with crutches, weight-bearing as comfort allows. Although it may still take 3 months or more f or the fracture to unite, the implant will be able to carry the load until union, allowing earlier return to function out of  the hospital. Femoral shaft fractures
Femoral shaft fractures in children are treated based on the age and size of  the child: /uni25CF infants (0–18 months); /uni25CF toddlers and small children (18 months–4 years); - /uni25CF children (4–12 years); /uni25CF older children/adolescents.
(b)
In infants (0–18 months), ensure that there is no evidence of non-accidental injury . In infants under 12–15 /uni00A0 kg, gallows traction is acceptable. This traction involves suspension of  the legs vertically with the buttocks just o ﬀ the bed. In toddlers and small children treatment is by traction initially followed by hip spica application. Shortening of  up to 1 /uni00A0 cm and angulation of  15–20° can be accepted depending on the age of  the child because of  extensive remodelling potential. As the child gets older and time to union increases, the non-operative measures of traction and hip spica become more cumbersome. In children from 4 to 12 years se veral treatment options exist: traction and hip spica, elastic stable intramedullary nailing (ESIN), external ﬁxation or plate ﬁxation. Deﬁnitive trea tment depends on surgeon skills, facilities and patient and parent needs. In older children and adolescents, non-operative treatment with traction and hip spica cast application becomes less toler able. Depending on the size and build of  the patient, operative treatment may include ESIN ( Figure 32.31 ), exter nal ﬁxation Augusto Sarmiento , b. 1927, Colombian orthopaedic surgeon, Professor and Chairman of  the Department of  Orthopedics, University of  Southern California, Los Angeles, CA, USA. or plate ﬁxation. In larger overweight adolescents, titanium elastic nails may not be strong enough to resist bending forces and locked intramedullary nailing may be considered. Summary box 32.6 Fractures in the skeletally immature /uni25CF /uni25CF /uni25CF /uni25CF It is important, however, to remember that there is a small chance of  avascular necrosis of  the femoral head if  an ante - grade intramedullary nail is used prior to or just after physeal closure. This is a rare but devastating complication in this age group. Far lateral entry point nails on the greater trochanter have been developed to limit the e ﬀ ect on the blood supply to the femoral head; however, the risk of  avascular necrosis persists.
(b)
Figure 32.30
Slipped left upper femoral epiphysis.
(a)
Plain radio
graph;
(b)
the injury highlighted.
Figure 32.31
(a–c)
Femoral shaft fracture in a child that has been
stabilised with elastic nails.
Do not forget non-accidental injury
Be reluctant to remanipulate a physeal injury
Elastic nails are a signi
/f_i
cant step forward in fracture treatment
in children
Not many fractures require operative intervention in children
Femoral shaft fractures
It is possible to treat diaphyseal fractures of  the femoral shaft non-operatively . The fracture can be reduced and held in position until union with traction; however, it takes 3 months. This is a long time to be in hospital and carries all the potential risks of  prolonged bed rest. Most femoral shaft fractures are treated with a locked intramedullary nail. With modern locked intramedullary implants, the patient will be up and out of  bed the following day and, if  it is an depends on the fracture pattern and implant used. If  there is a simple fracture pa ttern with cortical apposition, it will be possible to mobilise with crutches, weight-bearing as comfort allows. Although it may still take 3 months or more f or the fracture to unite, the implant will be able to carry the load until union, allowing earlier return to function out of  the hospital. Femoral shaft fractures
Femoral shaft fractures in children are treated based on the age and size of  the child: /uni25CF infants (0–18 months); /uni25CF toddlers and small children (18 months–4 years); - /uni25CF children (4–12 years); /uni25CF older children/adolescents.
(b)
In infants (0–18 months), ensure that there is no evidence of non-accidental injury . In infants under 12–15 /uni00A0 kg, gallows traction is acceptable. This traction involves suspension of  the legs vertically with the buttocks just o ﬀ the bed. In toddlers and small children treatment is by traction initially followed by hip spica application. Shortening of  up to 1 /uni00A0 cm and angulation of  15–20° can be accepted depending on the age of  the child because of  extensive remodelling potential. As the child gets older and time to union increases, the non-operative measures of traction and hip spica become more cumbersome. In children from 4 to 12 years se veral treatment options exist: traction and hip spica, elastic stable intramedullary nailing (ESIN), external ﬁxation or plate ﬁxation. Deﬁnitive trea tment depends on surgeon skills, facilities and patient and parent needs. In older children and adolescents, non-operative treatment with traction and hip spica cast application becomes less toler able. Depending on the size and build of  the patient, operative treatment may include ESIN ( Figure 32.31 ), exter nal ﬁxation Augusto Sarmiento , b. 1927, Colombian orthopaedic surgeon, Professor and Chairman of  the Department of  Orthopedics, University of  Southern California, Los Angeles, CA, USA. or plate ﬁxation. In larger overweight adolescents, titanium elastic nails may not be strong enough to resist bending forces and locked intramedullary nailing may be considered. Summary box 32.6 Fractures in the skeletally immature /uni25CF /uni25CF /uni25CF /uni25CF It is important, however, to remember that there is a small chance of  avascular necrosis of  the femoral head if  an ante - grade intramedullary nail is used prior to or just after physeal closure. This is a rare but devastating complication in this age group. Far lateral entry point nails on the greater trochanter have been developed to limit the e ﬀ ect on the blood supply to the femoral head; however, the risk of  avascular necrosis persists.
(b)
Figure 32.30
Slipped left upper femoral epiphysis.
(a)
Plain radio
graph;
(b)
the injury highlighted.
Figure 32.31
(a–c)
Femoral shaft fracture in a child that has been
stabilised with elastic nails.
Do not forget non-accidental injury
Be reluctant to remanipulate a physeal injury
Elastic nails are a signi
/f_i
cant step forward in fracture treatment
in children
Not many fractures require operative intervention in children

Forearm fractures (radius and ulna)
Forearm fractures (radius and ulna)
Fractures of  the diaphyseal shaft of  the radius and ulna are technically , in the anatomical sense of  the word, extra-articular. However, the forearm bones work together, being coupled at the proximal and distal radioulnar joints to allow for forearm pronation and supination. Therefore, when considering treatment the principles that apply to intra-articular fractures need to be considered: anatomical reduction and rigid ﬁxation to allow for early joint motion. Most fractures that involve both radius and ulna in adults require open reduction, anatomical alignment and rigid plate ﬁxation. ture, are a little more controversial, as non-operative manage - ment is possible but in this location risks delayed union and non-union, hence treatment depends on patient factors. Oper - ative ﬁxation with pla te and screw ﬁxation is technically simple and allows early predictable return to function. Forearm fractures (radius and ulna)
Fractures of  the diaphyseal shaft of  the radius and ulna are technically , in the anatomical sense of  the word, extra-articular. However, the forearm bones work together, being coupled at the proximal and distal radioulnar joints to allow for forearm pronation and supination. Therefore, when considering treatment the principles that apply to intra-articular fractures need to be considered: anatomical reduction and rigid ﬁxation to allow for early joint motion. Most fractures that involve both radius and ulna in adults require open reduction, anatomical alignment and rigid plate ﬁxation. ture, are a little more controversial, as non-operative manage - ment is possible but in this location risks delayed union and non-union, hence treatment depends on patient factors. Oper - ative ﬁxation with pla te and screw ﬁxation is technically simple and allows early predictable return to function. Forearm fractures (radius and ulna)
Fractures of  the diaphyseal shaft of  the radius and ulna are technically , in the anatomical sense of  the word, extra-articular. However, the forearm bones work together, being coupled at the proximal and distal radioulnar joints to allow for forearm pronation and supination. Therefore, when considering treatment the principles that apply to intra-articular fractures need to be considered: anatomical reduction and rigid ﬁxation to allow for early joint motion. Most fractures that involve both radius and ulna in adults require open reduction, anatomical alignment and rigid plate ﬁxation. ture, are a little more controversial, as non-operative manage - ment is possible but in this location risks delayed union and non-union, hence treatment depends on patient factors. Oper - ative ﬁxation with pla te and screw ﬁxation is technically simple and allows early predictable return to function.

Fractures of the proximal humerus
Fractures of the proximal humerus
In fractures of the proximal humerus consideration is given to the vascularity of  the humeral head. The most common classiﬁcation of  the proximal humerus is the Neer classiﬁca tion, which looks at the four individual pieces of  the proximal humerus (articular head fragment, lesser tuberosity , greater tuberosity and the shaft). If  a fragment is displaced by more than 1 /uni00A0 cm or angulated by more than 45° in respect of  another fragment, it is consid h, based on the fracture pattern, it may be ered a part. As suc undisplaced, or in two parts, three parts or four parts. Con tion is then given to potential joint dislocation, anterior sidera or posterior. The greater the number of  parts, the higher the hances of  interruption of  the vascularity to the humeral head c and the more complex the injury . hree factors can be used to predict avascularity of the T humeral head: 1 fracture through the anatomical neck; 2 loss of  the medial hinge; 3 less than 8 /uni00A0 mm of  bone along the medial calcar. In situations where there is a high risk of  failure of  both ﬁxation and  non-operative treatment, owing to avascular necrosis or implant ﬁxation failing from bone loss or loss of function (e.g. with displaced fractures in lower demand patients osis and other comorbidities), consid and those with osteopor eration may be given to replacing the humeral head. This may Charles Sumner Neer II , 1917–2011, American orthopedic surgeon, emeritus professor at Columbia University , developed a widely used shoulder prosthesis and also developed a common classiﬁcation system for proximal humerus fractures. limitations of trauma hemiarthroplasty for proximal humeral fractures involves r eliable healing of the tuberosities and the rotator cu ﬀ . Increasingly , a primary reverse polarity shoulder prosthesis is being used. This implant does not rely on tuber - osity healing, as it functions under the power of  the deltoid muscle. In younger patients reduction and ﬁxation may be consid - e available: percutaneous ered. A variety of ﬁxation methods ar ﬁxation, intramedullary nails and plate ﬁxation.
Figure 32.25
(a–c)
A B-type humeral shaft
fracture. This fracture could not be controlled
by non-operative means and was treated with
lag screws protected by a plate.
Fractures of the proximal humerus
In fractures of the proximal humerus consideration is given to the vascularity of  the humeral head. The most common classiﬁcation of  the proximal humerus is the Neer classiﬁca tion, which looks at the four individual pieces of  the proximal humerus (articular head fragment, lesser tuberosity , greater tuberosity and the shaft). If  a fragment is displaced by more than 1 /uni00A0 cm or angulated by more than 45° in respect of  another fragment, it is consid h, based on the fracture pattern, it may be ered a part. As suc undisplaced, or in two parts, three parts or four parts. Con tion is then given to potential joint dislocation, anterior sidera or posterior. The greater the number of  parts, the higher the hances of  interruption of  the vascularity to the humeral head c and the more complex the injury . hree factors can be used to predict avascularity of the T humeral head: 1 fracture through the anatomical neck; 2 loss of  the medial hinge; 3 less than 8 /uni00A0 mm of  bone along the medial calcar. In situations where there is a high risk of  failure of  both ﬁxation and  non-operative treatment, owing to avascular necrosis or implant ﬁxation failing from bone loss or loss of function (e.g. with displaced fractures in lower demand patients osis and other comorbidities), consid and those with osteopor eration may be given to replacing the humeral head. This may Charles Sumner Neer II , 1917–2011, American orthopedic surgeon, emeritus professor at Columbia University , developed a widely used shoulder prosthesis and also developed a common classiﬁcation system for proximal humerus fractures. limitations of trauma hemiarthroplasty for proximal humeral fractures involves r eliable healing of the tuberosities and the rotator cu ﬀ . Increasingly , a primary reverse polarity shoulder prosthesis is being used. This implant does not rely on tuber - osity healing, as it functions under the power of  the deltoid muscle. In younger patients reduction and ﬁxation may be consid - e available: percutaneous ered. A variety of ﬁxation methods ar ﬁxation, intramedullary nails and plate ﬁxation.
Figure 32.25
(a–c)
A B-type humeral shaft
fracture. This fracture could not be controlled
by non-operative means and was treated with
lag screws protected by a plate.
Fractures of the proximal humerus
In fractures of the proximal humerus consideration is given to the vascularity of  the humeral head. The most common classiﬁcation of  the proximal humerus is the Neer classiﬁca tion, which looks at the four individual pieces of  the proximal humerus (articular head fragment, lesser tuberosity , greater tuberosity and the shaft). If  a fragment is displaced by more than 1 /uni00A0 cm or angulated by more than 45° in respect of  another fragment, it is consid h, based on the fracture pattern, it may be ered a part. As suc undisplaced, or in two parts, three parts or four parts. Con tion is then given to potential joint dislocation, anterior sidera or posterior. The greater the number of  parts, the higher the hances of  interruption of  the vascularity to the humeral head c and the more complex the injury . hree factors can be used to predict avascularity of the T humeral head: 1 fracture through the anatomical neck; 2 loss of  the medial hinge; 3 less than 8 /uni00A0 mm of  bone along the medial calcar. In situations where there is a high risk of  failure of  both ﬁxation and  non-operative treatment, owing to avascular necrosis or implant ﬁxation failing from bone loss or loss of function (e.g. with displaced fractures in lower demand patients osis and other comorbidities), consid and those with osteopor eration may be given to replacing the humeral head. This may Charles Sumner Neer II , 1917–2011, American orthopedic surgeon, emeritus professor at Columbia University , developed a widely used shoulder prosthesis and also developed a common classiﬁcation system for proximal humerus fractures. limitations of trauma hemiarthroplasty for proximal humeral fractures involves r eliable healing of the tuberosities and the rotator cu ﬀ . Increasingly , a primary reverse polarity shoulder prosthesis is being used. This implant does not rely on tuber - osity healing, as it functions under the power of  the deltoid muscle. In younger patients reduction and ﬁxation may be consid - e available: percutaneous ered. A variety of ﬁxation methods ar ﬁxation, intramedullary nails and plate ﬁxation.
Figure 32.25
(a–c)
A B-type humeral shaft
fracture. This fracture could not be controlled
by non-operative means and was treated with
lag screws protected by a plate.

Heal
Heal
Time to fracture healing depends on several factors: patient comorbidities, the age of  the patient, bone involved (upper limb or lower limb), patient factors (diabetes) and choice of treatment. Well-known factors that slow down bone healing include diabetes mellitus (doubles time to union), diminished blood supply (peripheral vascular disease, vascular injury at the time of  injury), smoking, non-steroidal anti-inﬂammatory drugs and infection at the fracture site. Several chemical and mechanical methods have been attempted to enhance fracture healing, including bone marrow injections into the fracture site and other orthobiologics such as bone morphogenic proteins. Mechanical methods include controlled axial micromotion (using an external ﬁxator), elec tromagnetic stimulation and low-intensity pulsed ultrasound. There is good basic scientiﬁc evidence to support their theo retical beneﬁt; however, to date there is little clinical evidence for their use in the primary trea tment of  closed fractures. The surgical strategy is important in determining how bones heal. As surgeons, our technique helps dictate w hether the injury heals by primary bone healing, through compression; second ary bone healing, through forming callus that becomes ossiﬁed to bone over time; and, indeed, whether the fracture heals at all. Respecting the biological and biomechanical environment of  the fracture is an important consideration when planning operative and non-operativ e management of  fractures. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The main aim of  treatment is to return the patient to a similar level of premorbid function as quickly as possible. Rehabilita - tion begins as soon as feasible. It is often not necessary to wait until bone union before beginning rehabilitation. It is import - ant to move the a ﬀ ected joints and the joints in close proximity to the fracture (e.g. elbow and shoulder exercise while in a cast - f or a distal radial fracture), limiting global sti ﬀ ness and wasting of  the muscles on that limb.
TABLE 32.11
Indications for surgery in limb trauma. The
main indication is that operation will produce a better
outcome; the principles are given in the text.
A fracture requiring treatment that is unsuitable for non
operative measures
Open fractures
Failed non-operative management
Multiple injuries
Pathological or impending pathological fractures
Displaced intra-articular fractures
Fractures through the growth plate, where arrest is possible
(Salter–Harris types III–V)
Avulsion fractures that compromise the functional integrity of a
ligament/tendon around a joint (e.g. olecranon fracture)
Established non-unions or malunions
Heal
Time to fracture healing depends on several factors: patient comorbidities, the age of  the patient, bone involved (upper limb or lower limb), patient factors (diabetes) and choice of treatment. Well-known factors that slow down bone healing include diabetes mellitus (doubles time to union), diminished blood supply (peripheral vascular disease, vascular injury at the time of  injury), smoking, non-steroidal anti-inﬂammatory drugs and infection at the fracture site. Several chemical and mechanical methods have been attempted to enhance fracture healing, including bone marrow injections into the fracture site and other orthobiologics such as bone morphogenic proteins. Mechanical methods include controlled axial micromotion (using an external ﬁxator), elec tromagnetic stimulation and low-intensity pulsed ultrasound. There is good basic scientiﬁc evidence to support their theo retical beneﬁt; however, to date there is little clinical evidence for their use in the primary trea tment of  closed fractures. The surgical strategy is important in determining how bones heal. As surgeons, our technique helps dictate w hether the injury heals by primary bone healing, through compression; second ary bone healing, through forming callus that becomes ossiﬁed to bone over time; and, indeed, whether the fracture heals at all. Respecting the biological and biomechanical environment of  the fracture is an important consideration when planning operative and non-operativ e management of  fractures. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The main aim of  treatment is to return the patient to a similar level of premorbid function as quickly as possible. Rehabilita - tion begins as soon as feasible. It is often not necessary to wait until bone union before beginning rehabilitation. It is import - ant to move the a ﬀ ected joints and the joints in close proximity to the fracture (e.g. elbow and shoulder exercise while in a cast - f or a distal radial fracture), limiting global sti ﬀ ness and wasting of  the muscles on that limb.
TABLE 32.11
Indications for surgery in limb trauma. The
main indication is that operation will produce a better
outcome; the principles are given in the text.
A fracture requiring treatment that is unsuitable for non
operative measures
Open fractures
Failed non-operative management
Multiple injuries
Pathological or impending pathological fractures
Displaced intra-articular fractures
Fractures through the growth plate, where arrest is possible
(Salter–Harris types III–V)
Avulsion fractures that compromise the functional integrity of a
ligament/tendon around a joint (e.g. olecranon fracture)
Established non-unions or malunions
Heal
Time to fracture healing depends on several factors: patient comorbidities, the age of  the patient, bone involved (upper limb or lower limb), patient factors (diabetes) and choice of treatment. Well-known factors that slow down bone healing include diabetes mellitus (doubles time to union), diminished blood supply (peripheral vascular disease, vascular injury at the time of  injury), smoking, non-steroidal anti-inﬂammatory drugs and infection at the fracture site. Several chemical and mechanical methods have been attempted to enhance fracture healing, including bone marrow injections into the fracture site and other orthobiologics such as bone morphogenic proteins. Mechanical methods include controlled axial micromotion (using an external ﬁxator), elec tromagnetic stimulation and low-intensity pulsed ultrasound. There is good basic scientiﬁc evidence to support their theo retical beneﬁt; however, to date there is little clinical evidence for their use in the primary trea tment of  closed fractures. The surgical strategy is important in determining how bones heal. As surgeons, our technique helps dictate w hether the injury heals by primary bone healing, through compression; second ary bone healing, through forming callus that becomes ossiﬁed to bone over time; and, indeed, whether the fracture heals at all. Respecting the biological and biomechanical environment of  the fracture is an important consideration when planning operative and non-operativ e management of  fractures. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The main aim of  treatment is to return the patient to a similar level of premorbid function as quickly as possible. Rehabilita - tion begins as soon as feasible. It is often not necessary to wait until bone union before beginning rehabilitation. It is import - ant to move the a ﬀ ected joints and the joints in close proximity to the fracture (e.g. elbow and shoulder exercise while in a cast - f or a distal radial fracture), limiting global sti ﬀ ness and wasting of  the muscles on that limb.
TABLE 32.11
Indications for surgery in limb trauma. The
main indication is that operation will produce a better
outcome; the principles are given in the text.
A fracture requiring treatment that is unsuitable for non
operative measures
Open fractures
Failed non-operative management
Multiple injuries
Pathological or impending pathological fractures
Displaced intra-articular fractures
Fractures through the growth plate, where arrest is possible
(Salter–Harris types III–V)
Avulsion fractures that compromise the functional integrity of a
ligament/tendon around a joint (e.g. olecranon fracture)
Established non-unions or malunions

History
History
It is important to ascertain the mechanism of injury and the amount of  force involved in the injury . Take time to gather su ﬃ cient detail in order to do this. The mechanism of  injury gives an indication to the clinician of  the energy and forces imparted onto the patient. Certain injury mechanisms result in classical injury patterns; for example, electrocution or seizure activity may lead to a posterior dislocation of  the shoulder. In your mind translate the mechanism of  injury into the common - anatomical injury patterns. For example, a head-on collision between two cars each travelling at 40 miles per hour coming to a dead stop should be interpreted by the history taker as - a rapid deceleration injury , which then allows anticipation of likely injuries, such as rupture of  the aortic arch. Similarly , a fall onto an outstretched hand might be associated with wrist, - elbow , shoulder and clavicular injuries. Following the history of  the presenting complaint, it is important to collect information beyond that of the injury . T he AMPLE mnemonic is an abbreviated system taught in ATLS that is designed to provide key information quickly in a focused way . A : Allergies M : Medication – important to ask about anticoagulant and antiplatelet therapies, corticosteroid use and any possible immunosuppressive treatment P : Past medical and surgical history – has the patient had an anaesthetic in the past and were there any complications E : Events – events that led to the injury In the multiply injured patient or patients with altered levels of  consciousness, gain as much collateral history as possible. Listen to the account of  prehospital personnel; for example, the amount of cabin intrusion in a vehicle or whether a colli sion was head-on or side-on. History
It is important to ascertain the mechanism of injury and the amount of  force involved in the injury . Take time to gather su ﬃ cient detail in order to do this. The mechanism of  injury gives an indication to the clinician of  the energy and forces imparted onto the patient. Certain injury mechanisms result in classical injury patterns; for example, electrocution or seizure activity may lead to a posterior dislocation of  the shoulder. In your mind translate the mechanism of  injury into the common - anatomical injury patterns. For example, a head-on collision between two cars each travelling at 40 miles per hour coming to a dead stop should be interpreted by the history taker as - a rapid deceleration injury , which then allows anticipation of likely injuries, such as rupture of  the aortic arch. Similarly , a fall onto an outstretched hand might be associated with wrist, - elbow , shoulder and clavicular injuries. Following the history of  the presenting complaint, it is important to collect information beyond that of the injury . T he AMPLE mnemonic is an abbreviated system taught in ATLS that is designed to provide key information quickly in a focused way . A : Allergies M : Medication – important to ask about anticoagulant and antiplatelet therapies, corticosteroid use and any possible immunosuppressive treatment P : Past medical and surgical history – has the patient had an anaesthetic in the past and were there any complications E : Events – events that led to the injury In the multiply injured patient or patients with altered levels of  consciousness, gain as much collateral history as possible. Listen to the account of  prehospital personnel; for example, the amount of cabin intrusion in a vehicle or whether a colli sion was head-on or side-on. History
It is important to ascertain the mechanism of injury and the amount of  force involved in the injury . Take time to gather su ﬃ cient detail in order to do this. The mechanism of  injury gives an indication to the clinician of  the energy and forces imparted onto the patient. Certain injury mechanisms result in classical injury patterns; for example, electrocution or seizure activity may lead to a posterior dislocation of  the shoulder. In your mind translate the mechanism of  injury into the common - anatomical injury patterns. For example, a head-on collision between two cars each travelling at 40 miles per hour coming to a dead stop should be interpreted by the history taker as - a rapid deceleration injury , which then allows anticipation of likely injuries, such as rupture of  the aortic arch. Similarly , a fall onto an outstretched hand might be associated with wrist, - elbow , shoulder and clavicular injuries. Following the history of  the presenting complaint, it is important to collect information beyond that of the injury . T he AMPLE mnemonic is an abbreviated system taught in ATLS that is designed to provide key information quickly in a focused way . A : Allergies M : Medication – important to ask about anticoagulant and antiplatelet therapies, corticosteroid use and any possible immunosuppressive treatment P : Past medical and surgical history – has the patient had an anaesthetic in the past and were there any complications E : Events – events that led to the injury In the multiply injured patient or patients with altered levels of  consciousness, gain as much collateral history as possible. Listen to the account of  prehospital personnel; for example, the amount of cabin intrusion in a vehicle or whether a colli sion was head-on or side-on.

Hold
Hold
If  the fracture fragments are in an acceptable position, or have been reduced into an acceptable position, they then need to be held in that position until they heal. When choosing a method to hold a fracture the aim is to: /uni25CF optimise the biological and mechanical environment to create the most favourable conditions possible for fracture healing; Martin Kirschner , 1879–1942, Professor of  Surgery , Heidelberg, Germany , introduced the use of  skeletal traction wires in 1909. (f) (b) (c) (g) . (d) (h) - - Summary box 32.4 - Reduction /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF minimise the period of  disability by speeding up the heal - ing process or providing enough stability to return to nor - mal function while the fracture heals. There are several methods of  holding fracture fragments in place: /uni25CF plaster cast/splints; /uni25CF traction; /uni25CF Kirschner (K-) wires;
surface
Body
weight
Tension
surface
Ground
re
action
Increase deformity and
re
stor
e soft-tissue hinge
Dorsal surface
periosteum hinges
Vo
lar surface fails
in tension
Maximum
displacement
Close soft-tissue
hinge
With the injury force removed
Hold position with
the bones often recoil
three-point
/f_i
xation
to bayonet apposition
Figure 32.13
(a–d)
Representation of how the mechanism of injury
causes the bony and soft-tissue injury.
(e–h)
Representation of how
the residual mechanical properties of the tissues may be used to
effect and hold a reduction.
Reduction has two components: reducing the fragments and
assessing adequacy of reduction
Reduction can be performed open or closed
The principle is to reverse the movement that created the
fracture
Over-angulation allows the intact periosteum to guide the
fragments into position
/uni25CF plates and screws; /uni25CF intramedullary nails. Note : Arthroplasty may be used where fragments cannot be held together. On occasion a combination of  holding methods may be used; for example, K-wires and a moulded cast in the case of a simple extra-articular distal radial fracture. It is important to consider the way of  holding the reduction in terms of  outcome and ensure that this is part of  the overarching goal to optimise the patient’s return to function as safely and as fast as possible. For example, a displaced clavicle fracture in a 10-year old has a 99% chance of  sound union within a few months if treated non-operatively . In contrast, a displaced multifragmen tary middle third clavicle in a 35-year-old woman will carry a 35% chance of  going on to a non-union at 6 months. There fore, even though this fracture may heal with non-operative treatment, with appropriate explanation and shared decision making, a patient may choose to have surgery early in order to get back to normal function as soon as possible. Stability can be absolute or relative: /uni25CF Absolute stability . Implies no displacement or move ment and is achieved by accurate anatomical reduction with compression across the fracture fragments to optimise the environment for direct bone healing. This is desirable in intra-articular fractures, where callus at the fracture site might inhibit mov ement. Intra-articular fractures require an anatomical reduction and absolute stability . (a) (b) (c) Plaster of  Paris is a white crystalline powder, calcium sulphate hemihydrate CaSO ture site, optimising the environment for callus formation and indirect bone healing. Selected examples of  achieving absolute and relative stabil - ity are shown in Figure 32.14 . Plaster cast and splints Plaster casts and splints are generally used to hold stable fractures or supplement the ﬁxation of  unstable fractures (e.g. below-elbow cast applied to a distal radial fracture after K-wire ﬁxation [see Kirschner wires ]). - Plaster casts come in two forms: plaster of  Paris and syn - thetic casting materials. Plaster of  Paris is the preferred method - in acute fractures; where more support is needed, it is easier to mould plaster of  Paris than a synthetic cast. In acute injuries, - where there is a risk of  swelling and compartment syndrome, a backslab will often be applied. A backslab is not always posi - tioned on the dor sal surface as the name suggests, but is a par - tial cast where a layer of  plaster of  Paris or synthetic cast is applied along roughly half  the circumference. An alternative to a backslab includes a full cast that is split along its full length - to allow for swelling. The use of an incomplete cast does not remove the risk of  swelling and compartment syndrome and must always be accompanied by close clinical observation. Moulding of  the cast is an art form requiring appropriate skill to achieve the desired e ﬀ ect. Three-point moulding is used to control the position, often using the intact dorsal perios - teal hinge to mould against ( Figure 32.13 ). Often, a correctly (d) (e) (f) ·0.5H O, which sets hard when water is added to it. 4 2
Absolute stability
Lag screw
Compression plating
Compression with a ring
/f_i
xator
Figure 32.14 (a–f)
How absolute and relative stability can be achieved. The same implants may be used to achieve different mechanical effects.
Relative stability
Bridge plating
Intramedullary nail
Bridging with a ring
/f_i
xator
make straight bones’ ( Figure 32.15 ). Commercially available upper limb and lower limb splints provide comfort, support and social protection to stable frac tures. Ease of  application and the ability to remove them make them very useful for patients to r eturn to activities of  daily living, including bathing and showering. The advantages and disadvantages of  plaster cast and splint usage are described in Table 32.4 . /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Traction Traction is deﬁned as a stretching force on a limb to pull a fracture straight. After appropriate pain control, simply pulling on the limb using manual traction will help realign fracture fragments, returning overall length and alignment. If  the fracture is simple and o ﬀ -ended (displaced so the two bone ends are translated and misaligned), it may require more than simply pulling to reduce it (see reduction in Figure 32.13 Once reduced, however, continued longitudinal traction will often hold it reduced. A traction force can be applied and maintained by a vari ety of  systems and techniques. It is easy to apply traction to any extremity; however, it is cumbersome and requires a ﬁxed point to pull on. This can require the patient to be ﬁxed to one place and limit r eturn to normal function (see Table 32.5 advantages and disadvantages of  traction). /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Traction is often used in the treatment of  femoral shaft fractures in adults as a temporary measure for comfort and to allow transfer of  the patient, until deﬁnitive ﬁxation can be Hugh Owen Thomas , 1834–1891, general practitioner of  Liverpool, UK, is regarded as the founder of  orthopaedic surgery , although never holding a hospital appointment and preferring to treat patients in their own homes. He introduced the Thomas splint in 1875. - (b) undertaken. A Thomas splint is applied to the limb initially in a static fashion ( Figure 32.16a ) and then, once in bed, balanced traction is applied to help pull the leg out to length and pull the splint o ﬀ the ischial tuberosity ( Figure 32.16b ). ). (a) - for (b)
TABLE 32.4
Advantages and disadvantages of casting
and splinting.
Advantages
No wound
No interference with the fracture site
Cheap
Adjustable
No implants to remove
Disadvantages
Limited access to the soft tissues
Cumbersome (particularly in the elderly)
Interferes with function
Poor mechanical stability
‘Plaster disease’ – joint stiffness and muscle
wasting
TABLE 32.5
Advantages and disadvantages of traction.
Advantages
No wound in zone of injury
No interference with fracture site
Materials cheap
Adjustable
Disadvantages
Restricts mobility of patient
Expensive in hospital time
Skin pressure complications
Pin site infection
Thromboembolic complication
Figure 32.15
(a)
The position achieved at the end of the manipulation
described in
Figure 32.13
.
(b)
Demonstration of how, by moulding the
cast, the intact periosteum is kept under tension and the bone under
compression; thus, the remaining mechanical properties are used to
achieve stability.
ight
We
Figure 32.16
(a)
Static traction with a Thomas splint. The force and
counterforce are contained within a static system. The load is applied
to the patient through the tibial traction pin via a cord tightened with
a Spanish windlass. The counterforce is applied through pressure by
the splint on the ischial tuberosity.
(b)
A dynamic system in which
the load is applied by weights suspended from the tibial pin and the
counterforce is the patient’s own weight.
applying an adhesive or non-adhesive bandage, or skeletal traction, where a pin is placed in the proximal tibia or distal femur. A common everyday example of  traction is the use of a collar and cu ﬀ in proximal humeral fractures. When the patient is upright, the lower part of  the arm, under the action of  gravity , provides longitudinal traction, thus aligning the fractur e fragments. Kirschner wires Kirschner wires (also called K-wires) are smooth, non-threaded, thin ﬂ  exible wires often between 0.9 and 2.5 /uni00A0 mm in diameter. They are used to hold small fragments in place. They may be used in a temporary fashion intraoperatively to hold fracture fragments in place until deﬁ  nitive ﬁ  xation with plates and screws can be performed. They are inexpensive and simple to use. Moreover, they are extensively used for deﬁ  nitive ﬁ  xation of  injuries around the hand and wrist. The ﬂ  exible nature of  the wires can often require supplementation, as a hybrid construct of  K-wires and plaster cast ﬁ  xation. In distal radial fractures the wires are placed percutane ously after closed reduction, with the trailing end of  the wire left proud of  the skin and the end bent to limit wire migration. K-wires around the distal radius can be removed in the clinic setting 4–6 weeks after insertion. Complications of K-wires include pin site infection, wire breakage, loss of  ﬁ  xation and Gavriil Abramovich Ilizarov , 1921–1993, orthopaedic sur geon, Kurgan, Western Siberia, Russia. He did not attend school until he was 11 years old as his family was too poor to buy him shoes. J Charles Taylor , orthopaedic surgeon, Memphis, TN, USA. ous problem in certain locations. It is not advisable to use non-threaded K-wires around the shoulder girdle and clavi - cle as migration into the thoracic cavity and heart has been reported ( Table 32.6 ). /uni25CF /uni25CF /uni25CF /uni25CF External ﬁ  xation External ﬁ  xation involves percutaneous placement of  metal rods or ﬁ  ne wires into bone to anchor a metal frame on the outside ( Table 32.7 ). The frame construct itself  may consist of tubular rods with connectors, or a circular ring construct – the ‘Ilizarov’ frame. Hybrid variations are inﬁ  nite, with combina - tions of  anchor ﬁ  xation modalities and frame constructs. The Taylor spatial frame allows for gradual correction of  deformity - ( Figure 32.17 ). The major dra wback of  external ﬁ  xation is that they can be cumbersome to the patient and pin site infection can be a problem ( Table 32.7 ). Speciﬁ  c indications for external ﬁ  xators include:
(a)
(b)
Figure 32.17
(a)
Monolateral tubular frame with a metal rod (half pin anchorage to bone).
bone.
(c)
Hybrid circular/tubular rod frame construct with a combination of half pin and
/f_i
ne wire anchorage to bone.
allows for gradual correction of deformity.
TABLE 32.6
Indications for K-wire insertion.
Temporary
/f_i
xation
De
/f_i
nitive
/f_i
xation – with small fracture fragments (e.g. wrist
fractures and hand injuries)
Tension band wiring (fractures of the patella and olecranon)
Temporary immobilisation of a small joint
(c)
(d)
(b)
Circular ring
/f_i
xator with
/f_i
ne wire anchorage to
(d)
Taylor spatial frame;
/uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF emergency stabilisation of  a long bone fracture in the poly trauma patient thought too unwell to have other interven tions – damage control orthopaedics; /uni25CF stabilisation of  a dislocated joint after reduction (e.g. a spanning ﬁxator across the knee joint while the vascular surgeons repair an arterial injury with a knee dislocation); /uni25CF complex periarticular fractures to provide temporary stabi lisation and allow the soft-tissue damage to recover before deﬁnitive ﬁxation (e.g. a distal tibial [pilon] fracture); /uni25CF fractures associated with infection; /uni25CF treating fractures with bone loss. Plates and screws Plates and screws can be used in many di ﬀ erent ways. A ‘lag screw’ can be used to generate compression across a fracture site, optimising the environment for direct bone healing. Similarly , compression can be achieved using a dynamic compression plate. A plate might also be used simply to neutralise forces, buttress a fracture or work as an internal–external ﬁxator ( Figure 32.14 ). In general, plates and screws are used where possible in articular and periarticular fractures where an anatomical reduction is required, often via open means, followed by the application of  the plate and screws to achie ve a rigid construct. In extra-articular fractures, where mechanical alignment is required together with relative stability , one option is the use of  locking plate technology . This allows a closed reduction and percutaneous placement of  the plate with locking screws to create an internal construct, which behaves like an external ﬁxator. Injury-speciﬁc plating systems have revolutionised the /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF shaped for speciﬁc anatomical regions and speciﬁc injury pat - terns (see Table 32.8 for the advantages and disadvantages of plate ﬁxation). Intramedullary nails Diaphyseal fractures are best suited for intramedullary nailing. Where mechanical alignment is required together with rela - tive stability , they allow for indirect bone healing. After nail insertion, mechanical alignment is checked particularly for length, alignment and rotation. Locking screws are then placed pro ximally and distally to maintain length and alignment. Intramedullary nailing of  metaphyseal and articular fractures is a challenge. However, with improved implant design and the - ability to lock the nails very distally and in multiple directions, - the indications for intramedullary nailing are expanding. Intramedullary nails may be placed in an unreamed or reamed fashion. Reaming is the process whereby the intramed - ullary canal is widened slightly to allow passage of  a larger diameter nail, relating to the last reamer size used. Table 32.9 - compar es reamed with unreamed nails. Intramedullary nailing can be a technically demanding procedure. The advantages and disadv antages are summarised in Table 32.10 . /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Arthroplasty Arthroplasty is indicated in certain acute circumstances: articular fractures that are not reconstructible or injuries where the vascularity of  the articular segment is compromised (e.g. displaced intracapsular femoral neck fracture in an older patient).
/f_i
xation.
Advantages
No interference with fracture site
Adjustable after application: alignment;
biomechanics
Soft tissues accessible for plastic surgery
Rapid stabilisation of fracture
Hardware easy to remove
Disadvantages
Pin site infection
Interferes with plastic surgical procedures
Soft-tissue tethering
Cumbersome for the patient
TABLE 32.8
Advantages and disadvantages of plate and
screw
/f_i
xation.
Advantages
Can be used when anatomical
reduction is required
Allows early mobilisation
Can provide absolute or relative
stability
Disadvantages
May interfere with the fracture site
Periosteal/soft-tissue damage
Does not normally allow for
immediate load-bearing
Potential for infection
Metalwork complications
Possible need for plate removal
TABLE 32.9
A comparison of reamed and unreamed
nailing (an assumption is that nails used unreamed are
usually thinner than those used reamed).
Reamed IMN
Unreamed IMN
Insertion time
Longer
Quicker
Time to union
Shorter
Longer
Size of implant
Larger
Smaller
Reduction of distal
Easier
More dif
/f_i
cult
fractures
Strength of construct
More
Less
IMN, intramedullary nail.
TABLE 32.10
Advantages and disadvantages of
intramedullary nailing.
Advantages
Minimally invasive
Early weight-bearing
Less periosteal damage than open reduction
and internal
/f_i
xation
Seldom need removal
Disadvantages
Increased risk of fat emboli/chest
complications
Infection dif
/f_i
cult to treat
Dif
/f_i
cult to remove if broken
to be considered in choosing arthroplasty as a treatment option. Implant longevity and level of  activities following implant insertion need to be matched. Traditionally , arthroplasty for trauma was limited to hip and shoulder hemiarthroplasty . Total hip replacement, acute distal femoral replacement, radial head replacement, total and hemielbow arthroplasty and reverse polarity shoulder arthroplasty are curr ent treat ment options for older patients with osteoporotic periarticular fractures. The selection of  a particular technique will depend on clinical evidence and our previously stated aim to return patients to optimal function as soon as possible. It should be considered in the context tha t it can be expensive and require considerable other resources to make the procedure safe and long-lasting. Hold
If  the fracture fragments are in an acceptable position, or have been reduced into an acceptable position, they then need to be held in that position until they heal. When choosing a method to hold a fracture the aim is to: /uni25CF optimise the biological and mechanical environment to create the most favourable conditions possible for fracture healing; Martin Kirschner , 1879–1942, Professor of  Surgery , Heidelberg, Germany , introduced the use of  skeletal traction wires in 1909. (f) (b) (c) (g) . (d) (h) - - Summary box 32.4 - Reduction /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF minimise the period of  disability by speeding up the heal - ing process or providing enough stability to return to nor - mal function while the fracture heals. There are several methods of  holding fracture fragments in place: /uni25CF plaster cast/splints; /uni25CF traction; /uni25CF Kirschner (K-) wires;
surface
Body
weight
Tension
surface
Ground
re
action
Increase deformity and
re
stor
e soft-tissue hinge
Dorsal surface
periosteum hinges
Vo
lar surface fails
in tension
Maximum
displacement
Close soft-tissue
hinge
With the injury force removed
Hold position with
the bones often recoil
three-point
/f_i
xation
to bayonet apposition
Figure 32.13
(a–d)
Representation of how the mechanism of injury
causes the bony and soft-tissue injury.
(e–h)
Representation of how
the residual mechanical properties of the tissues may be used to
effect and hold a reduction.
Reduction has two components: reducing the fragments and
assessing adequacy of reduction
Reduction can be performed open or closed
The principle is to reverse the movement that created the
fracture
Over-angulation allows the intact periosteum to guide the
fragments into position
/uni25CF plates and screws; /uni25CF intramedullary nails. Note : Arthroplasty may be used where fragments cannot be held together. On occasion a combination of  holding methods may be used; for example, K-wires and a moulded cast in the case of a simple extra-articular distal radial fracture. It is important to consider the way of  holding the reduction in terms of  outcome and ensure that this is part of  the overarching goal to optimise the patient’s return to function as safely and as fast as possible. For example, a displaced clavicle fracture in a 10-year old has a 99% chance of  sound union within a few months if treated non-operatively . In contrast, a displaced multifragmen tary middle third clavicle in a 35-year-old woman will carry a 35% chance of  going on to a non-union at 6 months. There fore, even though this fracture may heal with non-operative treatment, with appropriate explanation and shared decision making, a patient may choose to have surgery early in order to get back to normal function as soon as possible. Stability can be absolute or relative: /uni25CF Absolute stability . Implies no displacement or move ment and is achieved by accurate anatomical reduction with compression across the fracture fragments to optimise the environment for direct bone healing. This is desirable in intra-articular fractures, where callus at the fracture site might inhibit mov ement. Intra-articular fractures require an anatomical reduction and absolute stability . (a) (b) (c) Plaster of  Paris is a white crystalline powder, calcium sulphate hemihydrate CaSO ture site, optimising the environment for callus formation and indirect bone healing. Selected examples of  achieving absolute and relative stabil - ity are shown in Figure 32.14 . Plaster cast and splints Plaster casts and splints are generally used to hold stable fractures or supplement the ﬁxation of  unstable fractures (e.g. below-elbow cast applied to a distal radial fracture after K-wire ﬁxation [see Kirschner wires ]). - Plaster casts come in two forms: plaster of  Paris and syn - thetic casting materials. Plaster of  Paris is the preferred method - in acute fractures; where more support is needed, it is easier to mould plaster of  Paris than a synthetic cast. In acute injuries, - where there is a risk of  swelling and compartment syndrome, a backslab will often be applied. A backslab is not always posi - tioned on the dor sal surface as the name suggests, but is a par - tial cast where a layer of  plaster of  Paris or synthetic cast is applied along roughly half  the circumference. An alternative to a backslab includes a full cast that is split along its full length - to allow for swelling. The use of an incomplete cast does not remove the risk of  swelling and compartment syndrome and must always be accompanied by close clinical observation. Moulding of  the cast is an art form requiring appropriate skill to achieve the desired e ﬀ ect. Three-point moulding is used to control the position, often using the intact dorsal perios - teal hinge to mould against ( Figure 32.13 ). Often, a correctly (d) (e) (f) ·0.5H O, which sets hard when water is added to it. 4 2
Absolute stability
Lag screw
Compression plating
Compression with a ring
/f_i
xator
Figure 32.14 (a–f)
How absolute and relative stability can be achieved. The same implants may be used to achieve different mechanical effects.
Relative stability
Bridge plating
Intramedullary nail
Bridging with a ring
/f_i
xator
make straight bones’ ( Figure 32.15 ). Commercially available upper limb and lower limb splints provide comfort, support and social protection to stable frac tures. Ease of  application and the ability to remove them make them very useful for patients to r eturn to activities of  daily living, including bathing and showering. The advantages and disadvantages of  plaster cast and splint usage are described in Table 32.4 . /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Traction Traction is deﬁned as a stretching force on a limb to pull a fracture straight. After appropriate pain control, simply pulling on the limb using manual traction will help realign fracture fragments, returning overall length and alignment. If  the fracture is simple and o ﬀ -ended (displaced so the two bone ends are translated and misaligned), it may require more than simply pulling to reduce it (see reduction in Figure 32.13 Once reduced, however, continued longitudinal traction will often hold it reduced. A traction force can be applied and maintained by a vari ety of  systems and techniques. It is easy to apply traction to any extremity; however, it is cumbersome and requires a ﬁxed point to pull on. This can require the patient to be ﬁxed to one place and limit r eturn to normal function (see Table 32.5 advantages and disadvantages of  traction). /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Traction is often used in the treatment of  femoral shaft fractures in adults as a temporary measure for comfort and to allow transfer of  the patient, until deﬁnitive ﬁxation can be Hugh Owen Thomas , 1834–1891, general practitioner of  Liverpool, UK, is regarded as the founder of  orthopaedic surgery , although never holding a hospital appointment and preferring to treat patients in their own homes. He introduced the Thomas splint in 1875. - (b) undertaken. A Thomas splint is applied to the limb initially in a static fashion ( Figure 32.16a ) and then, once in bed, balanced traction is applied to help pull the leg out to length and pull the splint o ﬀ the ischial tuberosity ( Figure 32.16b ). ). (a) - for (b)
TABLE 32.4
Advantages and disadvantages of casting
and splinting.
Advantages
No wound
No interference with the fracture site
Cheap
Adjustable
No implants to remove
Disadvantages
Limited access to the soft tissues
Cumbersome (particularly in the elderly)
Interferes with function
Poor mechanical stability
‘Plaster disease’ – joint stiffness and muscle
wasting
TABLE 32.5
Advantages and disadvantages of traction.
Advantages
No wound in zone of injury
No interference with fracture site
Materials cheap
Adjustable
Disadvantages
Restricts mobility of patient
Expensive in hospital time
Skin pressure complications
Pin site infection
Thromboembolic complication
Figure 32.15
(a)
The position achieved at the end of the manipulation
described in
Figure 32.13
.
(b)
Demonstration of how, by moulding the
cast, the intact periosteum is kept under tension and the bone under
compression; thus, the remaining mechanical properties are used to
achieve stability.
ight
We
Figure 32.16
(a)
Static traction with a Thomas splint. The force and
counterforce are contained within a static system. The load is applied
to the patient through the tibial traction pin via a cord tightened with
a Spanish windlass. The counterforce is applied through pressure by
the splint on the ischial tuberosity.
(b)
A dynamic system in which
the load is applied by weights suspended from the tibial pin and the
counterforce is the patient’s own weight.
applying an adhesive or non-adhesive bandage, or skeletal traction, where a pin is placed in the proximal tibia or distal femur. A common everyday example of  traction is the use of a collar and cu ﬀ in proximal humeral fractures. When the patient is upright, the lower part of  the arm, under the action of  gravity , provides longitudinal traction, thus aligning the fractur e fragments. Kirschner wires Kirschner wires (also called K-wires) are smooth, non-threaded, thin ﬂ  exible wires often between 0.9 and 2.5 /uni00A0 mm in diameter. They are used to hold small fragments in place. They may be used in a temporary fashion intraoperatively to hold fracture fragments in place until deﬁ  nitive ﬁ  xation with plates and screws can be performed. They are inexpensive and simple to use. Moreover, they are extensively used for deﬁ  nitive ﬁ  xation of  injuries around the hand and wrist. The ﬂ  exible nature of  the wires can often require supplementation, as a hybrid construct of  K-wires and plaster cast ﬁ  xation. In distal radial fractures the wires are placed percutane ously after closed reduction, with the trailing end of  the wire left proud of  the skin and the end bent to limit wire migration. K-wires around the distal radius can be removed in the clinic setting 4–6 weeks after insertion. Complications of K-wires include pin site infection, wire breakage, loss of  ﬁ  xation and Gavriil Abramovich Ilizarov , 1921–1993, orthopaedic sur geon, Kurgan, Western Siberia, Russia. He did not attend school until he was 11 years old as his family was too poor to buy him shoes. J Charles Taylor , orthopaedic surgeon, Memphis, TN, USA. ous problem in certain locations. It is not advisable to use non-threaded K-wires around the shoulder girdle and clavi - cle as migration into the thoracic cavity and heart has been reported ( Table 32.6 ). /uni25CF /uni25CF /uni25CF /uni25CF External ﬁ  xation External ﬁ  xation involves percutaneous placement of  metal rods or ﬁ  ne wires into bone to anchor a metal frame on the outside ( Table 32.7 ). The frame construct itself  may consist of tubular rods with connectors, or a circular ring construct – the ‘Ilizarov’ frame. Hybrid variations are inﬁ  nite, with combina - tions of  anchor ﬁ  xation modalities and frame constructs. The Taylor spatial frame allows for gradual correction of  deformity - ( Figure 32.17 ). The major dra wback of  external ﬁ  xation is that they can be cumbersome to the patient and pin site infection can be a problem ( Table 32.7 ). Speciﬁ  c indications for external ﬁ  xators include:
(a)
(b)
Figure 32.17
(a)
Monolateral tubular frame with a metal rod (half pin anchorage to bone).
bone.
(c)
Hybrid circular/tubular rod frame construct with a combination of half pin and
/f_i
ne wire anchorage to bone.
allows for gradual correction of deformity.
TABLE 32.6
Indications for K-wire insertion.
Temporary
/f_i
xation
De
/f_i
nitive
/f_i
xation – with small fracture fragments (e.g. wrist
fractures and hand injuries)
Tension band wiring (fractures of the patella and olecranon)
Temporary immobilisation of a small joint
(c)
(d)
(b)
Circular ring
/f_i
xator with
/f_i
ne wire anchorage to
(d)
Taylor spatial frame;
/uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF emergency stabilisation of  a long bone fracture in the poly trauma patient thought too unwell to have other interven tions – damage control orthopaedics; /uni25CF stabilisation of  a dislocated joint after reduction (e.g. a spanning ﬁxator across the knee joint while the vascular surgeons repair an arterial injury with a knee dislocation); /uni25CF complex periarticular fractures to provide temporary stabi lisation and allow the soft-tissue damage to recover before deﬁnitive ﬁxation (e.g. a distal tibial [pilon] fracture); /uni25CF fractures associated with infection; /uni25CF treating fractures with bone loss. Plates and screws Plates and screws can be used in many di ﬀ erent ways. A ‘lag screw’ can be used to generate compression across a fracture site, optimising the environment for direct bone healing. Similarly , compression can be achieved using a dynamic compression plate. A plate might also be used simply to neutralise forces, buttress a fracture or work as an internal–external ﬁxator ( Figure 32.14 ). In general, plates and screws are used where possible in articular and periarticular fractures where an anatomical reduction is required, often via open means, followed by the application of  the plate and screws to achie ve a rigid construct. In extra-articular fractures, where mechanical alignment is required together with relative stability , one option is the use of  locking plate technology . This allows a closed reduction and percutaneous placement of  the plate with locking screws to create an internal construct, which behaves like an external ﬁxator. Injury-speciﬁc plating systems have revolutionised the /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF shaped for speciﬁc anatomical regions and speciﬁc injury pat - terns (see Table 32.8 for the advantages and disadvantages of plate ﬁxation). Intramedullary nails Diaphyseal fractures are best suited for intramedullary nailing. Where mechanical alignment is required together with rela - tive stability , they allow for indirect bone healing. After nail insertion, mechanical alignment is checked particularly for length, alignment and rotation. Locking screws are then placed pro ximally and distally to maintain length and alignment. Intramedullary nailing of  metaphyseal and articular fractures is a challenge. However, with improved implant design and the - ability to lock the nails very distally and in multiple directions, - the indications for intramedullary nailing are expanding. Intramedullary nails may be placed in an unreamed or reamed fashion. Reaming is the process whereby the intramed - ullary canal is widened slightly to allow passage of  a larger diameter nail, relating to the last reamer size used. Table 32.9 - compar es reamed with unreamed nails. Intramedullary nailing can be a technically demanding procedure. The advantages and disadv antages are summarised in Table 32.10 . /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Arthroplasty Arthroplasty is indicated in certain acute circumstances: articular fractures that are not reconstructible or injuries where the vascularity of  the articular segment is compromised (e.g. displaced intracapsular femoral neck fracture in an older patient).
/f_i
xation.
Advantages
No interference with fracture site
Adjustable after application: alignment;
biomechanics
Soft tissues accessible for plastic surgery
Rapid stabilisation of fracture
Hardware easy to remove
Disadvantages
Pin site infection
Interferes with plastic surgical procedures
Soft-tissue tethering
Cumbersome for the patient
TABLE 32.8
Advantages and disadvantages of plate and
screw
/f_i
xation.
Advantages
Can be used when anatomical
reduction is required
Allows early mobilisation
Can provide absolute or relative
stability
Disadvantages
May interfere with the fracture site
Periosteal/soft-tissue damage
Does not normally allow for
immediate load-bearing
Potential for infection
Metalwork complications
Possible need for plate removal
TABLE 32.9
A comparison of reamed and unreamed
nailing (an assumption is that nails used unreamed are
usually thinner than those used reamed).
Reamed IMN
Unreamed IMN
Insertion time
Longer
Quicker
Time to union
Shorter
Longer
Size of implant
Larger
Smaller
Reduction of distal
Easier
More dif
/f_i
cult
fractures
Strength of construct
More
Less
IMN, intramedullary nail.
TABLE 32.10
Advantages and disadvantages of
intramedullary nailing.
Advantages
Minimally invasive
Early weight-bearing
Less periosteal damage than open reduction
and internal
/f_i
xation
Seldom need removal
Disadvantages
Increased risk of fat emboli/chest
complications
Infection dif
/f_i
cult to treat
Dif
/f_i
cult to remove if broken
to be considered in choosing arthroplasty as a treatment option. Implant longevity and level of  activities following implant insertion need to be matched. Traditionally , arthroplasty for trauma was limited to hip and shoulder hemiarthroplasty . Total hip replacement, acute distal femoral replacement, radial head replacement, total and hemielbow arthroplasty and reverse polarity shoulder arthroplasty are curr ent treat ment options for older patients with osteoporotic periarticular fractures. The selection of  a particular technique will depend on clinical evidence and our previously stated aim to return patients to optimal function as soon as possible. It should be considered in the context tha t it can be expensive and require considerable other resources to make the procedure safe and long-lasting. Hold
If  the fracture fragments are in an acceptable position, or have been reduced into an acceptable position, they then need to be held in that position until they heal. When choosing a method to hold a fracture the aim is to: /uni25CF optimise the biological and mechanical environment to create the most favourable conditions possible for fracture healing; Martin Kirschner , 1879–1942, Professor of  Surgery , Heidelberg, Germany , introduced the use of  skeletal traction wires in 1909. (f) (b) (c) (g) . (d) (h) - - Summary box 32.4 - Reduction /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF minimise the period of  disability by speeding up the heal - ing process or providing enough stability to return to nor - mal function while the fracture heals. There are several methods of  holding fracture fragments in place: /uni25CF plaster cast/splints; /uni25CF traction; /uni25CF Kirschner (K-) wires;
surface
Body
weight
Tension
surface
Ground
re
action
Increase deformity and
re
stor
e soft-tissue hinge
Dorsal surface
periosteum hinges
Vo
lar surface fails
in tension
Maximum
displacement
Close soft-tissue
hinge
With the injury force removed
Hold position with
the bones often recoil
three-point
/f_i
xation
to bayonet apposition
Figure 32.13
(a–d)
Representation of how the mechanism of injury
causes the bony and soft-tissue injury.
(e–h)
Representation of how
the residual mechanical properties of the tissues may be used to
effect and hold a reduction.
Reduction has two components: reducing the fragments and
assessing adequacy of reduction
Reduction can be performed open or closed
The principle is to reverse the movement that created the
fracture
Over-angulation allows the intact periosteum to guide the
fragments into position
/uni25CF plates and screws; /uni25CF intramedullary nails. Note : Arthroplasty may be used where fragments cannot be held together. On occasion a combination of  holding methods may be used; for example, K-wires and a moulded cast in the case of a simple extra-articular distal radial fracture. It is important to consider the way of  holding the reduction in terms of  outcome and ensure that this is part of  the overarching goal to optimise the patient’s return to function as safely and as fast as possible. For example, a displaced clavicle fracture in a 10-year old has a 99% chance of  sound union within a few months if treated non-operatively . In contrast, a displaced multifragmen tary middle third clavicle in a 35-year-old woman will carry a 35% chance of  going on to a non-union at 6 months. There fore, even though this fracture may heal with non-operative treatment, with appropriate explanation and shared decision making, a patient may choose to have surgery early in order to get back to normal function as soon as possible. Stability can be absolute or relative: /uni25CF Absolute stability . Implies no displacement or move ment and is achieved by accurate anatomical reduction with compression across the fracture fragments to optimise the environment for direct bone healing. This is desirable in intra-articular fractures, where callus at the fracture site might inhibit mov ement. Intra-articular fractures require an anatomical reduction and absolute stability . (a) (b) (c) Plaster of  Paris is a white crystalline powder, calcium sulphate hemihydrate CaSO ture site, optimising the environment for callus formation and indirect bone healing. Selected examples of  achieving absolute and relative stabil - ity are shown in Figure 32.14 . Plaster cast and splints Plaster casts and splints are generally used to hold stable fractures or supplement the ﬁxation of  unstable fractures (e.g. below-elbow cast applied to a distal radial fracture after K-wire ﬁxation [see Kirschner wires ]). - Plaster casts come in two forms: plaster of  Paris and syn - thetic casting materials. Plaster of  Paris is the preferred method - in acute fractures; where more support is needed, it is easier to mould plaster of  Paris than a synthetic cast. In acute injuries, - where there is a risk of  swelling and compartment syndrome, a backslab will often be applied. A backslab is not always posi - tioned on the dor sal surface as the name suggests, but is a par - tial cast where a layer of  plaster of  Paris or synthetic cast is applied along roughly half  the circumference. An alternative to a backslab includes a full cast that is split along its full length - to allow for swelling. The use of an incomplete cast does not remove the risk of  swelling and compartment syndrome and must always be accompanied by close clinical observation. Moulding of  the cast is an art form requiring appropriate skill to achieve the desired e ﬀ ect. Three-point moulding is used to control the position, often using the intact dorsal perios - teal hinge to mould against ( Figure 32.13 ). Often, a correctly (d) (e) (f) ·0.5H O, which sets hard when water is added to it. 4 2
Absolute stability
Lag screw
Compression plating
Compression with a ring
/f_i
xator
Figure 32.14 (a–f)
How absolute and relative stability can be achieved. The same implants may be used to achieve different mechanical effects.
Relative stability
Bridge plating
Intramedullary nail
Bridging with a ring
/f_i
xator
make straight bones’ ( Figure 32.15 ). Commercially available upper limb and lower limb splints provide comfort, support and social protection to stable frac tures. Ease of  application and the ability to remove them make them very useful for patients to r eturn to activities of  daily living, including bathing and showering. The advantages and disadvantages of  plaster cast and splint usage are described in Table 32.4 . /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Traction Traction is deﬁned as a stretching force on a limb to pull a fracture straight. After appropriate pain control, simply pulling on the limb using manual traction will help realign fracture fragments, returning overall length and alignment. If  the fracture is simple and o ﬀ -ended (displaced so the two bone ends are translated and misaligned), it may require more than simply pulling to reduce it (see reduction in Figure 32.13 Once reduced, however, continued longitudinal traction will often hold it reduced. A traction force can be applied and maintained by a vari ety of  systems and techniques. It is easy to apply traction to any extremity; however, it is cumbersome and requires a ﬁxed point to pull on. This can require the patient to be ﬁxed to one place and limit r eturn to normal function (see Table 32.5 advantages and disadvantages of  traction). /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Traction is often used in the treatment of  femoral shaft fractures in adults as a temporary measure for comfort and to allow transfer of  the patient, until deﬁnitive ﬁxation can be Hugh Owen Thomas , 1834–1891, general practitioner of  Liverpool, UK, is regarded as the founder of  orthopaedic surgery , although never holding a hospital appointment and preferring to treat patients in their own homes. He introduced the Thomas splint in 1875. - (b) undertaken. A Thomas splint is applied to the limb initially in a static fashion ( Figure 32.16a ) and then, once in bed, balanced traction is applied to help pull the leg out to length and pull the splint o ﬀ the ischial tuberosity ( Figure 32.16b ). ). (a) - for (b)
TABLE 32.4
Advantages and disadvantages of casting
and splinting.
Advantages
No wound
No interference with the fracture site
Cheap
Adjustable
No implants to remove
Disadvantages
Limited access to the soft tissues
Cumbersome (particularly in the elderly)
Interferes with function
Poor mechanical stability
‘Plaster disease’ – joint stiffness and muscle
wasting
TABLE 32.5
Advantages and disadvantages of traction.
Advantages
No wound in zone of injury
No interference with fracture site
Materials cheap
Adjustable
Disadvantages
Restricts mobility of patient
Expensive in hospital time
Skin pressure complications
Pin site infection
Thromboembolic complication
Figure 32.15
(a)
The position achieved at the end of the manipulation
described in
Figure 32.13
.
(b)
Demonstration of how, by moulding the
cast, the intact periosteum is kept under tension and the bone under
compression; thus, the remaining mechanical properties are used to
achieve stability.
ight
We
Figure 32.16
(a)
Static traction with a Thomas splint. The force and
counterforce are contained within a static system. The load is applied
to the patient through the tibial traction pin via a cord tightened with
a Spanish windlass. The counterforce is applied through pressure by
the splint on the ischial tuberosity.
(b)
A dynamic system in which
the load is applied by weights suspended from the tibial pin and the
counterforce is the patient’s own weight.
applying an adhesive or non-adhesive bandage, or skeletal traction, where a pin is placed in the proximal tibia or distal femur. A common everyday example of  traction is the use of a collar and cu ﬀ in proximal humeral fractures. When the patient is upright, the lower part of  the arm, under the action of  gravity , provides longitudinal traction, thus aligning the fractur e fragments. Kirschner wires Kirschner wires (also called K-wires) are smooth, non-threaded, thin ﬂ  exible wires often between 0.9 and 2.5 /uni00A0 mm in diameter. They are used to hold small fragments in place. They may be used in a temporary fashion intraoperatively to hold fracture fragments in place until deﬁ  nitive ﬁ  xation with plates and screws can be performed. They are inexpensive and simple to use. Moreover, they are extensively used for deﬁ  nitive ﬁ  xation of  injuries around the hand and wrist. The ﬂ  exible nature of  the wires can often require supplementation, as a hybrid construct of  K-wires and plaster cast ﬁ  xation. In distal radial fractures the wires are placed percutane ously after closed reduction, with the trailing end of  the wire left proud of  the skin and the end bent to limit wire migration. K-wires around the distal radius can be removed in the clinic setting 4–6 weeks after insertion. Complications of K-wires include pin site infection, wire breakage, loss of  ﬁ  xation and Gavriil Abramovich Ilizarov , 1921–1993, orthopaedic sur geon, Kurgan, Western Siberia, Russia. He did not attend school until he was 11 years old as his family was too poor to buy him shoes. J Charles Taylor , orthopaedic surgeon, Memphis, TN, USA. ous problem in certain locations. It is not advisable to use non-threaded K-wires around the shoulder girdle and clavi - cle as migration into the thoracic cavity and heart has been reported ( Table 32.6 ). /uni25CF /uni25CF /uni25CF /uni25CF External ﬁ  xation External ﬁ  xation involves percutaneous placement of  metal rods or ﬁ  ne wires into bone to anchor a metal frame on the outside ( Table 32.7 ). The frame construct itself  may consist of tubular rods with connectors, or a circular ring construct – the ‘Ilizarov’ frame. Hybrid variations are inﬁ  nite, with combina - tions of  anchor ﬁ  xation modalities and frame constructs. The Taylor spatial frame allows for gradual correction of  deformity - ( Figure 32.17 ). The major dra wback of  external ﬁ  xation is that they can be cumbersome to the patient and pin site infection can be a problem ( Table 32.7 ). Speciﬁ  c indications for external ﬁ  xators include:
(a)
(b)
Figure 32.17
(a)
Monolateral tubular frame with a metal rod (half pin anchorage to bone).
bone.
(c)
Hybrid circular/tubular rod frame construct with a combination of half pin and
/f_i
ne wire anchorage to bone.
allows for gradual correction of deformity.
TABLE 32.6
Indications for K-wire insertion.
Temporary
/f_i
xation
De
/f_i
nitive
/f_i
xation – with small fracture fragments (e.g. wrist
fractures and hand injuries)
Tension band wiring (fractures of the patella and olecranon)
Temporary immobilisation of a small joint
(c)
(d)
(b)
Circular ring
/f_i
xator with
/f_i
ne wire anchorage to
(d)
Taylor spatial frame;
/uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF emergency stabilisation of  a long bone fracture in the poly trauma patient thought too unwell to have other interven tions – damage control orthopaedics; /uni25CF stabilisation of  a dislocated joint after reduction (e.g. a spanning ﬁxator across the knee joint while the vascular surgeons repair an arterial injury with a knee dislocation); /uni25CF complex periarticular fractures to provide temporary stabi lisation and allow the soft-tissue damage to recover before deﬁnitive ﬁxation (e.g. a distal tibial [pilon] fracture); /uni25CF fractures associated with infection; /uni25CF treating fractures with bone loss. Plates and screws Plates and screws can be used in many di ﬀ erent ways. A ‘lag screw’ can be used to generate compression across a fracture site, optimising the environment for direct bone healing. Similarly , compression can be achieved using a dynamic compression plate. A plate might also be used simply to neutralise forces, buttress a fracture or work as an internal–external ﬁxator ( Figure 32.14 ). In general, plates and screws are used where possible in articular and periarticular fractures where an anatomical reduction is required, often via open means, followed by the application of  the plate and screws to achie ve a rigid construct. In extra-articular fractures, where mechanical alignment is required together with relative stability , one option is the use of  locking plate technology . This allows a closed reduction and percutaneous placement of  the plate with locking screws to create an internal construct, which behaves like an external ﬁxator. Injury-speciﬁc plating systems have revolutionised the /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF shaped for speciﬁc anatomical regions and speciﬁc injury pat - terns (see Table 32.8 for the advantages and disadvantages of plate ﬁxation). Intramedullary nails Diaphyseal fractures are best suited for intramedullary nailing. Where mechanical alignment is required together with rela - tive stability , they allow for indirect bone healing. After nail insertion, mechanical alignment is checked particularly for length, alignment and rotation. Locking screws are then placed pro ximally and distally to maintain length and alignment. Intramedullary nailing of  metaphyseal and articular fractures is a challenge. However, with improved implant design and the - ability to lock the nails very distally and in multiple directions, - the indications for intramedullary nailing are expanding. Intramedullary nails may be placed in an unreamed or reamed fashion. Reaming is the process whereby the intramed - ullary canal is widened slightly to allow passage of  a larger diameter nail, relating to the last reamer size used. Table 32.9 - compar es reamed with unreamed nails. Intramedullary nailing can be a technically demanding procedure. The advantages and disadv antages are summarised in Table 32.10 . /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Arthroplasty Arthroplasty is indicated in certain acute circumstances: articular fractures that are not reconstructible or injuries where the vascularity of  the articular segment is compromised (e.g. displaced intracapsular femoral neck fracture in an older patient).
/f_i
xation.
Advantages
No interference with fracture site
Adjustable after application: alignment;
biomechanics
Soft tissues accessible for plastic surgery
Rapid stabilisation of fracture
Hardware easy to remove
Disadvantages
Pin site infection
Interferes with plastic surgical procedures
Soft-tissue tethering
Cumbersome for the patient
TABLE 32.8
Advantages and disadvantages of plate and
screw
/f_i
xation.
Advantages
Can be used when anatomical
reduction is required
Allows early mobilisation
Can provide absolute or relative
stability
Disadvantages
May interfere with the fracture site
Periosteal/soft-tissue damage
Does not normally allow for
immediate load-bearing
Potential for infection
Metalwork complications
Possible need for plate removal
TABLE 32.9
A comparison of reamed and unreamed
nailing (an assumption is that nails used unreamed are
usually thinner than those used reamed).
Reamed IMN
Unreamed IMN
Insertion time
Longer
Quicker
Time to union
Shorter
Longer
Size of implant
Larger
Smaller
Reduction of distal
Easier
More dif
/f_i
cult
fractures
Strength of construct
More
Less
IMN, intramedullary nail.
TABLE 32.10
Advantages and disadvantages of
intramedullary nailing.
Advantages
Minimally invasive
Early weight-bearing
Less periosteal damage than open reduction
and internal
/f_i
xation
Seldom need removal
Disadvantages
Increased risk of fat emboli/chest
complications
Infection dif
/f_i
cult to treat
Dif
/f_i
cult to remove if broken
to be considered in choosing arthroplasty as a treatment option. Implant longevity and level of  activities following implant insertion need to be matched. Traditionally , arthroplasty for trauma was limited to hip and shoulder hemiarthroplasty . Total hip replacement, acute distal femoral replacement, radial head replacement, total and hemielbow arthroplasty and reverse polarity shoulder arthroplasty are curr ent treat ment options for older patients with osteoporotic periarticular fractures. The selection of  a particular technique will depend on clinical evidence and our previously stated aim to return patients to optimal function as soon as possible. It should be considered in the context tha t it can be expensive and require considerable other resources to make the procedure safe and long-lasting.

Humeral fractures
Humeral fractures
Fractures of  the diaphyseal portion of  the humeral shaft are extra-articular fractures and as such require mechanical alignment. Non-operative treatment with functional bracing will achieve union in an acceptable position within 12 weeks in over 80% of  cases. Gravity can provide traction on the arm and in conjunction with a humeral brace helps to hold alignment and allow early range of  motion of the elbow . Active shoulder abduction is avoided until fracture union to prevent varus deformity . Shoulder movement must not be absent during treatment and so gravity-assisted pendulum exercises are instituted early on to prevent shoulder sti ﬀ ness. As the fracture approaches the metaphyseal region of  the humerus it becomes mor e di ﬃ cult to control with humeral bracing. Distal third extra-articular fractures of  the humerus can be treated non-operatively in a humeral brace but have a tendency to go into varus. Articular fractures of  the distal humerus require anatomical reduction and stable ﬁxation to allow early joint movement. Internal ﬁxation is indicated for displaced intra-articular fractures, non-union or delayed union, open fractures, multiple injuries and those fractures not held in an acceptable position with brace treatment. Fixation of  diaphyseal fractures can be achie ved with intramedullary nailing or plate and screw ﬁxa - tion. Plate ﬁxation is associated with higher union rates and lower rates of  reintervention ( Figure 32.25 ). The radial nerve is the most commonly injured nerve in humeral shaft fractures. Trea tment of  a humeral shaft frac - ture with a concomitant radial nerve palsy remains topical. Most will recover spontaneously . In general, if  the nerve injury occur s at the time of the original injury , non-operative treat - ment can be considered. If  it occurs after the injury , for exam - ple at the time of  brace application, then it should be explored. When exploring the radial nerve, plate and screw ﬁxation is then undertaken to stabilise the humerus. Humeral fractures
Fractures of  the diaphyseal portion of  the humeral shaft are extra-articular fractures and as such require mechanical alignment. Non-operative treatment with functional bracing will achieve union in an acceptable position within 12 weeks in over 80% of  cases. Gravity can provide traction on the arm and in conjunction with a humeral brace helps to hold alignment and allow early range of  motion of the elbow . Active shoulder abduction is avoided until fracture union to prevent varus deformity . Shoulder movement must not be absent during treatment and so gravity-assisted pendulum exercises are instituted early on to prevent shoulder sti ﬀ ness. As the fracture approaches the metaphyseal region of  the humerus it becomes mor e di ﬃ cult to control with humeral bracing. Distal third extra-articular fractures of  the humerus can be treated non-operatively in a humeral brace but have a tendency to go into varus. Articular fractures of  the distal humerus require anatomical reduction and stable ﬁxation to allow early joint movement. Internal ﬁxation is indicated for displaced intra-articular fractures, non-union or delayed union, open fractures, multiple injuries and those fractures not held in an acceptable position with brace treatment. Fixation of  diaphyseal fractures can be achie ved with intramedullary nailing or plate and screw ﬁxa - tion. Plate ﬁxation is associated with higher union rates and lower rates of  reintervention ( Figure 32.25 ). The radial nerve is the most commonly injured nerve in humeral shaft fractures. Trea tment of  a humeral shaft frac - ture with a concomitant radial nerve palsy remains topical. Most will recover spontaneously . In general, if  the nerve injury occur s at the time of the original injury , non-operative treat - ment can be considered. If  it occurs after the injury , for exam - ple at the time of  brace application, then it should be explored. When exploring the radial nerve, plate and screw ﬁxation is then undertaken to stabilise the humerus. Humeral fractures
Fractures of  the diaphyseal portion of  the humeral shaft are extra-articular fractures and as such require mechanical alignment. Non-operative treatment with functional bracing will achieve union in an acceptable position within 12 weeks in over 80% of  cases. Gravity can provide traction on the arm and in conjunction with a humeral brace helps to hold alignment and allow early range of  motion of the elbow . Active shoulder abduction is avoided until fracture union to prevent varus deformity . Shoulder movement must not be absent during treatment and so gravity-assisted pendulum exercises are instituted early on to prevent shoulder sti ﬀ ness. As the fracture approaches the metaphyseal region of  the humerus it becomes mor e di ﬃ cult to control with humeral bracing. Distal third extra-articular fractures of  the humerus can be treated non-operatively in a humeral brace but have a tendency to go into varus. Articular fractures of  the distal humerus require anatomical reduction and stable ﬁxation to allow early joint movement. Internal ﬁxation is indicated for displaced intra-articular fractures, non-union or delayed union, open fractures, multiple injuries and those fractures not held in an acceptable position with brace treatment. Fixation of  diaphyseal fractures can be achie ved with intramedullary nailing or plate and screw ﬁxa - tion. Plate ﬁxation is associated with higher union rates and lower rates of  reintervention ( Figure 32.25 ). The radial nerve is the most commonly injured nerve in humeral shaft fractures. Trea tment of  a humeral shaft frac - ture with a concomitant radial nerve palsy remains topical. Most will recover spontaneously . In general, if  the nerve injury occur s at the time of the original injury , non-operative treat - ment can be considered. If  it occurs after the injury , for exam - ple at the time of  brace application, then it should be explored. When exploring the radial nerve, plate and screw ﬁxation is then undertaken to stabilise the humerus.

Intra-articular fractures
Intra-articular fractures
AO type B and type C fractures are intra-articular and as such the principles of treating intra-articular fractures need to be respected; namely , anatomical reduction of  the articular surface and rigid stabilisation to allow early joint movement and avoid ance of  degenerative joint disease ( Figure 32.19 ). However, these principles have to be balanced with the increased wound complications of  open surgery and devitalising bone fragments with excessive exposure of  the bone. Osteoporotic intra-articular fractures are a considerable - challenge. Although anatomical reduction may be achieved, rigid ﬁxation devices may cut out of  soft bone, particularly in the metaphysis of  the bone where pull-out strength of  the ﬁx - ation is reduced. Plate design and the introduction of  locking plates where the screw secures itself  into the plate are design
(d)
(e)
Figure 32.18
(a)
and
(d)
are C-type or segmental tibial fractures. Each was a high-energy injury;
/f_i
xator applied in each case;
(c)
and
(f)
show de
/f_i
nitive relative stability was achieved with different methods of bridging
/f_i
xation. Healing was
by indirect means in both cases. Despite irregularities at the fracture sites the overall alignment in coronal and sagittal planes was satisfactory
and function was good.
(f)
(b)
and
(e)
show a temporary spanning external
features to help improve cut-out strength and may help reduce failure of ﬁxation in osteoporotic bone. Injectable bone substi tutes may be used to ﬁll bone voids and augment ﬁxation. If stable ﬁxation is not possible, then consideration might be given to non-operative treatment and delayed joint replacement or, on occasion, primary joint re placement may be undertaken. AA BB In type C fractures where the articular surface has sepa - rated from the metaphysis, the articular surface is initially - anatomically reduced and held with temporary K-wires or lag screws and then the articular block is reattached to the , nail or frame shaft using methods as described above – plate ( Figure 32.20 ).
(b)
(c)
Figure 32.19
A B-type or partial articular fracture.
(a)
Plain radiograph;
(b)
computed tomography clari
/f_i
es the injury;
(c)
/f_i
xation with plate and
screws achieving compression across a previously reduced fracture.
(b)
Figure 32.20
(a)
A C-type proximal tibial articular fracture (i.e. none
of the joint remains attached to the diaphysis).
(b)
The small plate
and screws (AA) are used to compress the joint fragments, aiming for
absolute stability. The heavy duty
/f_i
xed angled device (BB) spans the
fracture and provides relative stability. Although the image is historical
and techniques vary with time, there has been good restoration of
alignment and joint congruity.
Intra-articular fractures
AO type B and type C fractures are intra-articular and as such the principles of treating intra-articular fractures need to be respected; namely , anatomical reduction of  the articular surface and rigid stabilisation to allow early joint movement and avoid ance of  degenerative joint disease ( Figure 32.19 ). However, these principles have to be balanced with the increased wound complications of  open surgery and devitalising bone fragments with excessive exposure of  the bone. Osteoporotic intra-articular fractures are a considerable - challenge. Although anatomical reduction may be achieved, rigid ﬁxation devices may cut out of  soft bone, particularly in the metaphysis of  the bone where pull-out strength of  the ﬁx - ation is reduced. Plate design and the introduction of  locking plates where the screw secures itself  into the plate are design
(d)
(e)
Figure 32.18
(a)
and
(d)
are C-type or segmental tibial fractures. Each was a high-energy injury;
/f_i
xator applied in each case;
(c)
and
(f)
show de
/f_i
nitive relative stability was achieved with different methods of bridging
/f_i
xation. Healing was
by indirect means in both cases. Despite irregularities at the fracture sites the overall alignment in coronal and sagittal planes was satisfactory
and function was good.
(f)
(b)
and
(e)
show a temporary spanning external
features to help improve cut-out strength and may help reduce failure of ﬁxation in osteoporotic bone. Injectable bone substi tutes may be used to ﬁll bone voids and augment ﬁxation. If stable ﬁxation is not possible, then consideration might be given to non-operative treatment and delayed joint replacement or, on occasion, primary joint re placement may be undertaken. AA BB In type C fractures where the articular surface has sepa - rated from the metaphysis, the articular surface is initially - anatomically reduced and held with temporary K-wires or lag screws and then the articular block is reattached to the , nail or frame shaft using methods as described above – plate ( Figure 32.20 ).
(b)
(c)
Figure 32.19
A B-type or partial articular fracture.
(a)
Plain radiograph;
(b)
computed tomography clari
/f_i
es the injury;
(c)
/f_i
xation with plate and
screws achieving compression across a previously reduced fracture.
(b)
Figure 32.20
(a)
A C-type proximal tibial articular fracture (i.e. none
of the joint remains attached to the diaphysis).
(b)
The small plate
and screws (AA) are used to compress the joint fragments, aiming for
absolute stability. The heavy duty
/f_i
xed angled device (BB) spans the
fracture and provides relative stability. Although the image is historical
and techniques vary with time, there has been good restoration of
alignment and joint congruity.
Intra-articular fractures
AO type B and type C fractures are intra-articular and as such the principles of treating intra-articular fractures need to be respected; namely , anatomical reduction of  the articular surface and rigid stabilisation to allow early joint movement and avoid ance of  degenerative joint disease ( Figure 32.19 ). However, these principles have to be balanced with the increased wound complications of  open surgery and devitalising bone fragments with excessive exposure of  the bone. Osteoporotic intra-articular fractures are a considerable - challenge. Although anatomical reduction may be achieved, rigid ﬁxation devices may cut out of  soft bone, particularly in the metaphysis of  the bone where pull-out strength of  the ﬁx - ation is reduced. Plate design and the introduction of  locking plates where the screw secures itself  into the plate are design
(d)
(e)
Figure 32.18
(a)
and
(d)
are C-type or segmental tibial fractures. Each was a high-energy injury;
/f_i
xator applied in each case;
(c)
and
(f)
show de
/f_i
nitive relative stability was achieved with different methods of bridging
/f_i
xation. Healing was
by indirect means in both cases. Despite irregularities at the fracture sites the overall alignment in coronal and sagittal planes was satisfactory
and function was good.
(f)
(b)
and
(e)
show a temporary spanning external
features to help improve cut-out strength and may help reduce failure of ﬁxation in osteoporotic bone. Injectable bone substi tutes may be used to ﬁll bone voids and augment ﬁxation. If stable ﬁxation is not possible, then consideration might be given to non-operative treatment and delayed joint replacement or, on occasion, primary joint re placement may be undertaken. AA BB In type C fractures where the articular surface has sepa - rated from the metaphysis, the articular surface is initially - anatomically reduced and held with temporary K-wires or lag screws and then the articular block is reattached to the , nail or frame shaft using methods as described above – plate ( Figure 32.20 ).
(b)
(c)
Figure 32.19
A B-type or partial articular fracture.
(a)
Plain radiograph;
(b)
computed tomography clari
/f_i
es the injury;
(c)
/f_i
xation with plate and
screws achieving compression across a previously reduced fracture.
(b)
Figure 32.20
(a)
A C-type proximal tibial articular fracture (i.e. none
of the joint remains attached to the diaphysis).
(b)
The small plate
and screws (AA) are used to compress the joint fragments, aiming for
absolute stability. The heavy duty
/f_i
xed angled device (BB) spans the
fracture and provides relative stability. Although the image is historical
and techniques vary with time, there has been good restoration of
alignment and joint congruity.

Intracapsular femoral neck fractures
Intracapsular femoral neck fractures
Intracapsular fractures are further broken down into whether they are displaced or undisplaced. Undisplaced intracapsular fractures are generally stable and interruption of  the blood supply to the femoral head is rare. Therefore, treatment is aimed at ensuring that the head fragment does not displace during rehabilitation. This can be achieved with cannulated screws inserted along the femoral neck into the head. - A displaced intracapsular fracture may cause disruption of the blood supply either through direct injury to the arteries (a) (b) or joint capsule intra-articular haematoma can a ﬀ ect the sur vival of the femoral head, leading to avascular necrosis. If  the patient is physiologically young, reduction and internal ﬁxa tion with cannulated screws or a dynamic hip screw might be attempted to preserve the native head. If  the pa tient is older and would beneﬁt from a single oper ation, the head may be sacriﬁced and replaced with a pros thetic head. Arthroplasty of  the pr oximal femur may take the form of  hemiarthroplasty or total hip replacement, depending on the patient’s functional demands. Extracapsular femoral neck fractures If  the fracture is extracapsular, vascularity of  the head is not an issue. Extracapsular femoral neck fractures are subdivided into stable or unstable. Unstable fractures include a reverse oblique pattern or where the medial calcar is a comminuted (lesser trochanter) fracture. Stable extracapsular fractures simply require connection of  the head to the shaft, often using a dynamic hip screw ( Figure 32.26 ). In unstable fractures a dynamic hip screw can also be used, but, owing to the unfavourable mechanical environment relat ing to the loss of  the medial calcar or a reverse oblique patter an intramedullary device might be considered.
Dynamic hip
screw
Smooth bar
re
l in which
screw can slide
Figure 32.26
(a)
A dynamic hip screw for
/f_i
xing a trochanteric proxi
mal femoral fracture. This allows for compression at the fracture site
on load-bearing and protects the femoral head from penetration by
the screw when the osteoporotic bone settles;
(b)
insert to show the
sliding screw in the barrel.
Intracapsular femoral neck fractures
Intracapsular fractures are further broken down into whether they are displaced or undisplaced. Undisplaced intracapsular fractures are generally stable and interruption of  the blood supply to the femoral head is rare. Therefore, treatment is aimed at ensuring that the head fragment does not displace during rehabilitation. This can be achieved with cannulated screws inserted along the femoral neck into the head. - A displaced intracapsular fracture may cause disruption of the blood supply either through direct injury to the arteries (a) (b) or joint capsule intra-articular haematoma can a ﬀ ect the sur vival of the femoral head, leading to avascular necrosis. If  the patient is physiologically young, reduction and internal ﬁxa tion with cannulated screws or a dynamic hip screw might be attempted to preserve the native head. If  the pa tient is older and would beneﬁt from a single oper ation, the head may be sacriﬁced and replaced with a pros thetic head. Arthroplasty of  the pr oximal femur may take the form of  hemiarthroplasty or total hip replacement, depending on the patient’s functional demands. Extracapsular femoral neck fractures If  the fracture is extracapsular, vascularity of  the head is not an issue. Extracapsular femoral neck fractures are subdivided into stable or unstable. Unstable fractures include a reverse oblique pattern or where the medial calcar is a comminuted (lesser trochanter) fracture. Stable extracapsular fractures simply require connection of  the head to the shaft, often using a dynamic hip screw ( Figure 32.26 ). In unstable fractures a dynamic hip screw can also be used, but, owing to the unfavourable mechanical environment relat ing to the loss of  the medial calcar or a reverse oblique patter an intramedullary device might be considered.
Dynamic hip
screw
Smooth bar
re
l in which
screw can slide
Figure 32.26
(a)
A dynamic hip screw for
/f_i
xing a trochanteric proxi
mal femoral fracture. This allows for compression at the fracture site
on load-bearing and protects the femoral head from penetration by
the screw when the osteoporotic bone settles;
(b)
insert to show the
sliding screw in the barrel.
Intracapsular femoral neck fractures
Intracapsular fractures are further broken down into whether they are displaced or undisplaced. Undisplaced intracapsular fractures are generally stable and interruption of  the blood supply to the femoral head is rare. Therefore, treatment is aimed at ensuring that the head fragment does not displace during rehabilitation. This can be achieved with cannulated screws inserted along the femoral neck into the head. - A displaced intracapsular fracture may cause disruption of the blood supply either through direct injury to the arteries (a) (b) or joint capsule intra-articular haematoma can a ﬀ ect the sur vival of the femoral head, leading to avascular necrosis. If  the patient is physiologically young, reduction and internal ﬁxa tion with cannulated screws or a dynamic hip screw might be attempted to preserve the native head. If  the pa tient is older and would beneﬁt from a single oper ation, the head may be sacriﬁced and replaced with a pros thetic head. Arthroplasty of  the pr oximal femur may take the form of  hemiarthroplasty or total hip replacement, depending on the patient’s functional demands. Extracapsular femoral neck fractures If  the fracture is extracapsular, vascularity of  the head is not an issue. Extracapsular femoral neck fractures are subdivided into stable or unstable. Unstable fractures include a reverse oblique pattern or where the medial calcar is a comminuted (lesser trochanter) fracture. Stable extracapsular fractures simply require connection of  the head to the shaft, often using a dynamic hip screw ( Figure 32.26 ). In unstable fractures a dynamic hip screw can also be used, but, owing to the unfavourable mechanical environment relat ing to the loss of  the medial calcar or a reverse oblique patter an intramedullary device might be considered.
Dynamic hip
screw
Smooth bar
re
l in which
screw can slide
Figure 32.26
(a)
A dynamic hip screw for
/f_i
xing a trochanteric proxi
mal femoral fracture. This allows for compression at the fracture site
on load-bearing and protects the femoral head from penetration by
the screw when the osteoporotic bone settles;
(b)
insert to show the
sliding screw in the barrel.

Introduction
INTRODUCTION
In several chapters the importance of  life-threatening trauma is emphasised, but numerically for every patient who dies follow ing a traumatic event there are three who are left with a lifelong functional impairment. Extremity trauma can be thought of as injury in isolation or in the context of  trauma to the whole body . In the latter scenario extremity trauma and the mode in which it is managed may be important, as is the physiological stability of the patient – a concept known as damage control orthopaedic surgery . Furthermore, extremity trauma not only involves the bones, most obviously through a fracture, but also involves the surrounding soft-tissue envelope and thus could describe injury to nerves, other connective tissue and skin. The goal of  extremity trauma management is to return the injured area to optimal function as quickly as possible and therefore return function to the patient. The management of extremity trauma is step-wise and involves initially sa ving the patient’s life by the identiﬁcation and treatment of  life- and limb-threatening injuries, according to the Advanced Trauma Life Support (ATLS) principles. ATLS principles are a use ful starting point in the evaluation of  extremity trauma. They put the injury into context, attributing to it a priority in the management of  all the patient’s injuries; for example, a trau matic head injury may require management bef ore operative femoral fracture stabilisation with an intramedullary nail, yet the application of  traction to the a ﬀ ected limb, or an exter nal ﬁxator, may reduce the physiological insult to the patient as a whole. T herefore, the context of  extremity trauma is extremely important. Applying the principles of  ATLS in the initial assessment, f ollowed by damage control orthopaedics in the ongoing surgical management, provides a framework for patient management. One could summarise this by noting that treatment depends on patient factors, injury-speciﬁc factors and surgeon factors, including the resources available. It is imperative f or the clinician to involve the patient in the decision-making process when it comes to the choice of treatment for that individual. Moreover, treatment priorities, functional demands and risk versus beneﬁt vary from individ - ual to individual. -
The range of available treatments
•
How to select an appropriate treatment
•

Investigations
Investigations
The mainstay of  extremity trauma investigation remains radi - ography of  the a ﬀ ected limb to see if  there is a bony injury . However, this is not the sole investigation available. - Haematological investigations Simple haematological investigations are seldom useful in the evaluation of a single limb injury . In the polytrauma patient a full blood count, serum biochemistry , clotting factor and creatinine kinase may be useful. A blood gas, including pH, base excess and lactate, can be useful to show the severity of the injury and the response to resuscitation. Ultrasound Ultrasound is very useful to deﬁne soft-tissue injuries. Fractures of  the bones can be visualised on ultrasound but generally it is reserved for the soft tissues. One limitation of ultrasound is the variability depending on the experience of the sonographer. Radiography Radiographs are the mainstay in the initial evaluation of  suspected extremity trauma. The rule of  2s should be remembered: planes to avoid missing a fracture out of  plane on the ﬁrst radiograph view . For shoulder injuries ensure at least an anteroposterior and axillary or modiﬁed axillary view ( Figure 32.3 ). /uni25CF 2 joints – radiographs are required of  the joint above and the joint below the fracture. /uni25CF 2 occasions – sometimes the fracture may not be initially visible; a second series of  radiographs should be under - taken after 10–14 days if  suspicion of  bony injury persists. The classic injury here is a scaphoid fracture. If  initial scaphoid views are normal, consider repeating them 10– 14 days later if  pain and tenderness in the anatomical snu ﬀ box ( Figure 32.4 ) persist. /uni25CF 2 sides – in paediatric injuries it can be useful to consider a radiograph from the opposite and uninjured side if  doubt exists. With improved access to atlases of  normal variants this is less important. Computed axial tomography Computed axial tomography (CT) is very good for character - ising the bony anatomy of injuries, allowing for multiplanar reconstruction of  injury anatomy and providing other three-dimensional information. It is very useful f or periarticu - lar injuries, where the exact characterisation of  the bony injury is essential. A CT with contrast creating a CT angiogram provides very useful information regarding the vascularity and its association with the fracture. T he CT angiogram also gives an indication to plastic reconstruction surgeons of  reconstruc - tive options for limb trauma. Surface volume rendering is a useful addition allowing for easier visualisation of  the injury ( Figure 32.1b ). CT angiogra - phy ( Figure 32.2b ) may be added, providing informa tion on the vascular anatomy . One disadvantage of  CT is the dose of radiation involved. Magnetic resonance imaging Magnetic resonance imaging (MRI) provides three- dimensional information without the radiation involved in CT . It provides useful information, particularly about the soft tissues. MRI can provide information on the blood supply to the bone; for example, avascular necrosis of  the proximal pole of  the scaphoid. One disadvantage of MRI is the time taken to acquire the image; patients su ﬀ ering from claustrophobia ﬁnd the experience traumatic. It is essential to ensure patient safety and consideration should be given to potential risks of  MRI that may apply , for example with certain implanted devices and metallic foreign bodies, e.g. in the eye (see MHRA guidance in Further reading ). MRI angiography can also be performed, providing infor - mation about the vascular anatomy . Nuclear medicine scans Technetium-99 nuclear medicine scans register osteoblastic activity and may be used to demonstrate occult fractures; for example, an undisplaced scaphoid fracture.
(b)
Figure 32.2
(a)
Initial anterior tibiofemoral dislocation.
(b)
Postreduc
tion computed tomography angiogram showing complete blockage
of the popliteal artery with reconstitution distally from a collateral
blood supply.
Harald Tscherne , b. 1933, Austrian trauma surgeon, Director of  the Trauma Department, Medical Graduate School, Hannover, Germany . Ramon Balgoa Gustilo , surgeon, Hennepin County Medical Center, Minneapolis, MN, USA. John T Anderson , surgeon, Hennepin Medical Center, Minneapolis, MA, USA. 10 4 2 5 3 1 9 11 8 6 7 12 Summary box 32.1 History, examination and investigations /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
(b)
(c)
Figure 32.3
Radiographic series of the same patient demonstrating
the value of two views in two planes and the true value of the axil
lary view in shoulder trauma.
(a)
Anteroposterior radiograph of the
shoulder, initially reported as normal.
(b)
Lateral scapula radiograph,
initially reported as normal; humeral head slightly posteriorly directed.
(c)
Axillary view – true value of the axillary view shown with obvious
posterior dislocation of the glenohumeral joint.
Figure 32.4
Surface anatomy of the anatomical snuffbox: 1, cephalic
vein (blue); 2, radial nerve (yellow); 3, radial artery (red); 4, lower end
of radius; 5, scaphoid; 6, trapezium; 7,
/f_i
rst metacarpal; 8, proximal
phalanx; 9, distal phalanx; 10, extensor pollicis longus; 11, extensor
pollicis brevis; 12, abductor pollicis longus. (Reproduced with permis
sion from Lumley JSP , Craven JL, Abrahams PH, Tunstall RG.
Bailey &
Love’s essential clinical anatomy
. Boca Raton, FL: CRC Press, 2019.)
Follow a systematic approach
History requires suf
/f_i
cient detail of injury
History can be organised in the AMPLE format
Examination follows look, feel, move, special tests approach
Investigations will include radiographs with the rule of ‘2s’
observed
Selective use of special investigations can help diagnosis
Investigations
The mainstay of  extremity trauma investigation remains radi - ography of  the a ﬀ ected limb to see if  there is a bony injury . However, this is not the sole investigation available. - Haematological investigations Simple haematological investigations are seldom useful in the evaluation of a single limb injury . In the polytrauma patient a full blood count, serum biochemistry , clotting factor and creatinine kinase may be useful. A blood gas, including pH, base excess and lactate, can be useful to show the severity of the injury and the response to resuscitation. Ultrasound Ultrasound is very useful to deﬁne soft-tissue injuries. Fractures of  the bones can be visualised on ultrasound but generally it is reserved for the soft tissues. One limitation of ultrasound is the variability depending on the experience of the sonographer. Radiography Radiographs are the mainstay in the initial evaluation of  suspected extremity trauma. The rule of  2s should be remembered: planes to avoid missing a fracture out of  plane on the ﬁrst radiograph view . For shoulder injuries ensure at least an anteroposterior and axillary or modiﬁed axillary view ( Figure 32.3 ). /uni25CF 2 joints – radiographs are required of  the joint above and the joint below the fracture. /uni25CF 2 occasions – sometimes the fracture may not be initially visible; a second series of  radiographs should be under - taken after 10–14 days if  suspicion of  bony injury persists. The classic injury here is a scaphoid fracture. If  initial scaphoid views are normal, consider repeating them 10– 14 days later if  pain and tenderness in the anatomical snu ﬀ box ( Figure 32.4 ) persist. /uni25CF 2 sides – in paediatric injuries it can be useful to consider a radiograph from the opposite and uninjured side if  doubt exists. With improved access to atlases of  normal variants this is less important. Computed axial tomography Computed axial tomography (CT) is very good for character - ising the bony anatomy of injuries, allowing for multiplanar reconstruction of  injury anatomy and providing other three-dimensional information. It is very useful f or periarticu - lar injuries, where the exact characterisation of  the bony injury is essential. A CT with contrast creating a CT angiogram provides very useful information regarding the vascularity and its association with the fracture. T he CT angiogram also gives an indication to plastic reconstruction surgeons of  reconstruc - tive options for limb trauma. Surface volume rendering is a useful addition allowing for easier visualisation of  the injury ( Figure 32.1b ). CT angiogra - phy ( Figure 32.2b ) may be added, providing informa tion on the vascular anatomy . One disadvantage of  CT is the dose of radiation involved. Magnetic resonance imaging Magnetic resonance imaging (MRI) provides three- dimensional information without the radiation involved in CT . It provides useful information, particularly about the soft tissues. MRI can provide information on the blood supply to the bone; for example, avascular necrosis of  the proximal pole of  the scaphoid. One disadvantage of MRI is the time taken to acquire the image; patients su ﬀ ering from claustrophobia ﬁnd the experience traumatic. It is essential to ensure patient safety and consideration should be given to potential risks of  MRI that may apply , for example with certain implanted devices and metallic foreign bodies, e.g. in the eye (see MHRA guidance in Further reading ). MRI angiography can also be performed, providing infor - mation about the vascular anatomy . Nuclear medicine scans Technetium-99 nuclear medicine scans register osteoblastic activity and may be used to demonstrate occult fractures; for example, an undisplaced scaphoid fracture.
(b)
Figure 32.2
(a)
Initial anterior tibiofemoral dislocation.
(b)
Postreduc
tion computed tomography angiogram showing complete blockage
of the popliteal artery with reconstitution distally from a collateral
blood supply.
Harald Tscherne , b. 1933, Austrian trauma surgeon, Director of  the Trauma Department, Medical Graduate School, Hannover, Germany . Ramon Balgoa Gustilo , surgeon, Hennepin County Medical Center, Minneapolis, MN, USA. John T Anderson , surgeon, Hennepin Medical Center, Minneapolis, MA, USA. 10 4 2 5 3 1 9 11 8 6 7 12 Summary box 32.1 History, examination and investigations /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
(b)
(c)
Figure 32.3
Radiographic series of the same patient demonstrating
the value of two views in two planes and the true value of the axil
lary view in shoulder trauma.
(a)
Anteroposterior radiograph of the
shoulder, initially reported as normal.
(b)
Lateral scapula radiograph,
initially reported as normal; humeral head slightly posteriorly directed.
(c)
Axillary view – true value of the axillary view shown with obvious
posterior dislocation of the glenohumeral joint.
Figure 32.4
Surface anatomy of the anatomical snuffbox: 1, cephalic
vein (blue); 2, radial nerve (yellow); 3, radial artery (red); 4, lower end
of radius; 5, scaphoid; 6, trapezium; 7,
/f_i
rst metacarpal; 8, proximal
phalanx; 9, distal phalanx; 10, extensor pollicis longus; 11, extensor
pollicis brevis; 12, abductor pollicis longus. (Reproduced with permis
sion from Lumley JSP , Craven JL, Abrahams PH, Tunstall RG.
Bailey &
Love’s essential clinical anatomy
. Boca Raton, FL: CRC Press, 2019.)
Follow a systematic approach
History requires suf
/f_i
cient detail of injury
History can be organised in the AMPLE format
Examination follows look, feel, move, special tests approach
Investigations will include radiographs with the rule of ‘2s’
observed
Selective use of special investigations can help diagnosis
Investigations
The mainstay of  extremity trauma investigation remains radi - ography of  the a ﬀ ected limb to see if  there is a bony injury . However, this is not the sole investigation available. - Haematological investigations Simple haematological investigations are seldom useful in the evaluation of a single limb injury . In the polytrauma patient a full blood count, serum biochemistry , clotting factor and creatinine kinase may be useful. A blood gas, including pH, base excess and lactate, can be useful to show the severity of the injury and the response to resuscitation. Ultrasound Ultrasound is very useful to deﬁne soft-tissue injuries. Fractures of  the bones can be visualised on ultrasound but generally it is reserved for the soft tissues. One limitation of ultrasound is the variability depending on the experience of the sonographer. Radiography Radiographs are the mainstay in the initial evaluation of  suspected extremity trauma. The rule of  2s should be remembered: planes to avoid missing a fracture out of  plane on the ﬁrst radiograph view . For shoulder injuries ensure at least an anteroposterior and axillary or modiﬁed axillary view ( Figure 32.3 ). /uni25CF 2 joints – radiographs are required of  the joint above and the joint below the fracture. /uni25CF 2 occasions – sometimes the fracture may not be initially visible; a second series of  radiographs should be under - taken after 10–14 days if  suspicion of  bony injury persists. The classic injury here is a scaphoid fracture. If  initial scaphoid views are normal, consider repeating them 10– 14 days later if  pain and tenderness in the anatomical snu ﬀ box ( Figure 32.4 ) persist. /uni25CF 2 sides – in paediatric injuries it can be useful to consider a radiograph from the opposite and uninjured side if  doubt exists. With improved access to atlases of  normal variants this is less important. Computed axial tomography Computed axial tomography (CT) is very good for character - ising the bony anatomy of injuries, allowing for multiplanar reconstruction of  injury anatomy and providing other three-dimensional information. It is very useful f or periarticu - lar injuries, where the exact characterisation of  the bony injury is essential. A CT with contrast creating a CT angiogram provides very useful information regarding the vascularity and its association with the fracture. T he CT angiogram also gives an indication to plastic reconstruction surgeons of  reconstruc - tive options for limb trauma. Surface volume rendering is a useful addition allowing for easier visualisation of  the injury ( Figure 32.1b ). CT angiogra - phy ( Figure 32.2b ) may be added, providing informa tion on the vascular anatomy . One disadvantage of  CT is the dose of radiation involved. Magnetic resonance imaging Magnetic resonance imaging (MRI) provides three- dimensional information without the radiation involved in CT . It provides useful information, particularly about the soft tissues. MRI can provide information on the blood supply to the bone; for example, avascular necrosis of  the proximal pole of  the scaphoid. One disadvantage of MRI is the time taken to acquire the image; patients su ﬀ ering from claustrophobia ﬁnd the experience traumatic. It is essential to ensure patient safety and consideration should be given to potential risks of  MRI that may apply , for example with certain implanted devices and metallic foreign bodies, e.g. in the eye (see MHRA guidance in Further reading ). MRI angiography can also be performed, providing infor - mation about the vascular anatomy . Nuclear medicine scans Technetium-99 nuclear medicine scans register osteoblastic activity and may be used to demonstrate occult fractures; for example, an undisplaced scaphoid fracture.
(b)
Figure 32.2
(a)
Initial anterior tibiofemoral dislocation.
(b)
Postreduc
tion computed tomography angiogram showing complete blockage
of the popliteal artery with reconstitution distally from a collateral
blood supply.
Harald Tscherne , b. 1933, Austrian trauma surgeon, Director of  the Trauma Department, Medical Graduate School, Hannover, Germany . Ramon Balgoa Gustilo , surgeon, Hennepin County Medical Center, Minneapolis, MN, USA. John T Anderson , surgeon, Hennepin Medical Center, Minneapolis, MA, USA. 10 4 2 5 3 1 9 11 8 6 7 12 Summary box 32.1 History, examination and investigations /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
(b)
(c)
Figure 32.3
Radiographic series of the same patient demonstrating
the value of two views in two planes and the true value of the axil
lary view in shoulder trauma.
(a)
Anteroposterior radiograph of the
shoulder, initially reported as normal.
(b)
Lateral scapula radiograph,
initially reported as normal; humeral head slightly posteriorly directed.
(c)
Axillary view – true value of the axillary view shown with obvious
posterior dislocation of the glenohumeral joint.
Figure 32.4
Surface anatomy of the anatomical snuffbox: 1, cephalic
vein (blue); 2, radial nerve (yellow); 3, radial artery (red); 4, lower end
of radius; 5, scaphoid; 6, trapezium; 7,
/f_i
rst metacarpal; 8, proximal
phalanx; 9, distal phalanx; 10, extensor pollicis longus; 11, extensor
pollicis brevis; 12, abductor pollicis longus. (Reproduced with permis
sion from Lumley JSP , Craven JL, Abrahams PH, Tunstall RG.
Bailey &
Love’s essential clinical anatomy
. Boca Raton, FL: CRC Press, 2019.)
Follow a systematic approach
History requires suf
/f_i
cient detail of injury
History can be organised in the AMPLE format
Examination follows look, feel, move, special tests approach
Investigations will include radiographs with the rule of ‘2s’
observed
Selective use of special investigations can help diagnosis

Lateral condylar mass fracture of the elbow
Lateral condylar mass fracture of the elbow
Lateral condylar mass fractures of  the elbow are easily missed and often considered benign as there is often only a small ﬂake of bone visible. This thin sliver of metaphyseal bone on the lateral side of  the elbow is very deceptive. Do not underesti mate the signiﬁcance of  this injury ( Figure 32.29 ). Richard von Volkmann , 1830–1889, Professor of  Surgery , Halle, Germany . ment. If  stable, non-operative treatment is acceptable. If  unsta - ble, anatomical reduction and ﬁxation should be attempted to avoid complications. Unstable fractures are suggested by signiﬁcant soft-tissue swelling, by fracture displacement of  more than 2 /uni00A0 mm or by the fractur e being visible on both anteroposterior and lateral - views of  the elbow . Unstable fractures r equire anatomical reduction and rigid ﬁxation with K-wires or screw ﬁxation to avoid displacement - and complications. Avascular necrosis of  the capitellum and non-union of  the lateral condyle lead to the so-called ‘ﬁsh tail’ deformity .
(a)
Figure 32.29
Lateral condylar mass
fracture.
(a)
The metaphyseal fracture.
(b)
The yellow shows the shape of the
distal humerus, including the cartilagi
nous analogue, and the red shows the
true extent of the injury (i.e. a signi
/f_i
cant
intra-articular fracture).
Lateral condylar mass fracture of the elbow
Lateral condylar mass fractures of  the elbow are easily missed and often considered benign as there is often only a small ﬂake of bone visible. This thin sliver of metaphyseal bone on the lateral side of  the elbow is very deceptive. Do not underesti mate the signiﬁcance of  this injury ( Figure 32.29 ). Richard von Volkmann , 1830–1889, Professor of  Surgery , Halle, Germany . ment. If  stable, non-operative treatment is acceptable. If  unsta - ble, anatomical reduction and ﬁxation should be attempted to avoid complications. Unstable fractures are suggested by signiﬁcant soft-tissue swelling, by fracture displacement of  more than 2 /uni00A0 mm or by the fractur e being visible on both anteroposterior and lateral - views of  the elbow . Unstable fractures r equire anatomical reduction and rigid ﬁxation with K-wires or screw ﬁxation to avoid displacement - and complications. Avascular necrosis of  the capitellum and non-union of  the lateral condyle lead to the so-called ‘ﬁsh tail’ deformity .
(a)
Figure 32.29
Lateral condylar mass
fracture.
(a)
The metaphyseal fracture.
(b)
The yellow shows the shape of the
distal humerus, including the cartilagi
nous analogue, and the red shows the
true extent of the injury (i.e. a signi
/f_i
cant
intra-articular fracture).
Lateral condylar mass fracture of the elbow
Lateral condylar mass fractures of  the elbow are easily missed and often considered benign as there is often only a small ﬂake of bone visible. This thin sliver of metaphyseal bone on the lateral side of  the elbow is very deceptive. Do not underesti mate the signiﬁcance of  this injury ( Figure 32.29 ). Richard von Volkmann , 1830–1889, Professor of  Surgery , Halle, Germany . ment. If  stable, non-operative treatment is acceptable. If  unsta - ble, anatomical reduction and ﬁxation should be attempted to avoid complications. Unstable fractures are suggested by signiﬁcant soft-tissue swelling, by fracture displacement of  more than 2 /uni00A0 mm or by the fractur e being visible on both anteroposterior and lateral - views of  the elbow . Unstable fractures r equire anatomical reduction and rigid ﬁxation with K-wires or screw ﬁxation to avoid displacement - and complications. Avascular necrosis of  the capitellum and non-union of  the lateral condyle lead to the so-called ‘ﬁsh tail’ deformity .
(a)
Figure 32.29
Lateral condylar mass
fracture.
(a)
The metaphyseal fracture.
(b)
The yellow shows the shape of the
distal humerus, including the cartilagi
nous analogue, and the red shows the
true extent of the injury (i.e. a signi
/f_i
cant
intra-articular fracture).

Learning objectives
Learning objectives
To gain an understanding of: How to identify whether an injury exists • The important injuries not to miss • The principles of the description and classi /f_i cation of • fractures Learning objectives
To gain an understanding of: How to identify whether an injury exists • The important injuries not to miss • The principles of the description and classi /f_i cation of • fractures Learning objectives
To gain an understanding of: How to identify whether an injury exists • The important injuries not to miss • The principles of the description and classi /f_i cation of • fractures

Metaphyseal fractures
Metaphyseal fractures
In the AO classiﬁcation metaphyseal fractures are classiﬁed into A type – extra-articular, B type – partial articular, and C type – complete articular. In A-type fractures, joint congruity is not an issue and as such the principles of  mechanical alignment, length and rota - tion need to be considered. Fixation of  metaphyseal fractures is less predictable with intramedullary nailing, therefore pla te and screw ﬁxation, e xternal ﬁxation or, in the smaller joints, K-wire ﬁxation is used. Metaphyseal fractures are close to the joint and so consideration is given to stable ﬁxation to allow early joint movement and rehabilitation. Metaphyseal fractures
In the AO classiﬁcation metaphyseal fractures are classiﬁed into A type – extra-articular, B type – partial articular, and C type – complete articular. In A-type fractures, joint congruity is not an issue and as such the principles of  mechanical alignment, length and rota - tion need to be considered. Fixation of  metaphyseal fractures is less predictable with intramedullary nailing, therefore pla te and screw ﬁxation, e xternal ﬁxation or, in the smaller joints, K-wire ﬁxation is used. Metaphyseal fractures are close to the joint and so consideration is given to stable ﬁxation to allow early joint movement and rehabilitation. Metaphyseal fractures
In the AO classiﬁcation metaphyseal fractures are classiﬁed into A type – extra-articular, B type – partial articular, and C type – complete articular. In A-type fractures, joint congruity is not an issue and as such the principles of  mechanical alignment, length and rota - tion need to be considered. Fixation of  metaphyseal fractures is less predictable with intramedullary nailing, therefore pla te and screw ﬁxation, e xternal ﬁxation or, in the smaller joints, K-wire ﬁxation is used. Metaphyseal fractures are close to the joint and so consideration is given to stable ﬁxation to allow early joint movement and rehabilitation.

Olecranon fractures
Olecranon fractures
Olecranon fractures may be displaced or undisplaced. Undisplaced fractures with <2 /uni00A0 mm gap or step at the articular surface can be treated non-operatively . In displaced fractures the extensor mechanism is interrupted and the articular surface requires anatomical reduction and stable ﬁxation to allow early movement. Fixation may comprise K-wire and ﬁgure-of-eight tension band wiring or plate ﬁxation. In multifragmentary fractures or fractures associated with an elbow dislocation, increased stability is required with the use of  a plate and screws. Olecranon fractures
Olecranon fractures may be displaced or undisplaced. Undisplaced fractures with <2 /uni00A0 mm gap or step at the articular surface can be treated non-operatively . In displaced fractures the extensor mechanism is interrupted and the articular surface requires anatomical reduction and stable ﬁxation to allow early movement. Fixation may comprise K-wire and ﬁgure-of-eight tension band wiring or plate ﬁxation. In multifragmentary fractures or fractures associated with an elbow dislocation, increased stability is required with the use of  a plate and screws. Olecranon fractures
Olecranon fractures may be displaced or undisplaced. Undisplaced fractures with <2 /uni00A0 mm gap or step at the articular surface can be treated non-operatively . In displaced fractures the extensor mechanism is interrupted and the articular surface requires anatomical reduction and stable ﬁxation to allow early movement. Fixation may comprise K-wire and ﬁgure-of-eight tension band wiring or plate ﬁxation. In multifragmentary fractures or fractures associated with an elbow dislocation, increased stability is required with the use of  a plate and screws.

Open fractures
Open fractures
Any fracture with an overlying wound should be considered an open fracture. The term previously used was a compound fracture. Open fractures require particular mention because adequate stabilisation of  the bony injury and appropriate management of  the soft-tissue injury are paramount to ensure a good outcome with a low complication rate. The treatment of  bone and joint infection is expensive, laborious and time-consuming for the professional as well as the patient. An infected femoral shaft fracture following intramedullary nailing will typically take 3 years and ﬁve operations to clear the infection and achieve union. The Gustilo and Anderson classiﬁcation of  open fractures is the most frequently used classiﬁcation ( Table 32.2 ). The deﬁnitive grade is determined intraoperatively after thorough debridement. It is not based on size of  wound alone but takes into account sev eral factors; for example, a farmyard or heavily contaminated wound of  under 1 /uni00A0 cm may still be considered a grade III injury . - ould
(b)
(a)
Figure 32.32
Variations in
/f_i
xation technique suited to osteoporotic
bone.
(a)
Norian bone substitute has been injected to support the
lateral tibial plateau in the partial articular fracture.
(b)
A locking plate
in a proximal humerus. The screws are threaded into the plate to make
a
/f_i
xed-angle device.
union, optimise function and avoid infection. The treatment of open fractures should be considered in two phases: the emer gency department presurgical phase and the surgical phase. Presurgical phase 1 Take a photograph to document the severity of  the injury and limit the need for repeated opening of  dressings. (Do not delay steps below unduly .) 2 Assess neurovascular status; if compromised and the frac ture is displaced, quickly remove any macroscopic dirt and reduce the fracture/dislocation. It is not essential to achieve an anatomical reduction; simply remove the pres sure from the soft tissues (make a leg look like a leg and an arm look like an ar m). If  the bone was out of  the skin and is reduced under the skin, then document clearly and inform the surgical team. 3 Once overall alignment is achieved, splint the a ﬀ ected limb; treatment of  an open fracture is treatment of  the soft tissues. 4 Apply a moist saline dressing to the wound. It is accept able to irrigate the wound with saline in the emergency department to remove any macroscopic dirt, but deﬁnitive debridement and washout of  the wound should be under taken in a thea tre environment. 5 Administer intravenous antibiotics according to local protocols. It has been shown that early administration of intravenous antibiotics is one of  the most important steps. A broad-spectrum antibiotic should be chosen covering Gram-positive, Gram-negative and, if  there is severe con tamination, anaerobic organisms. 6 Obtain a tetanus immunisation history and treat accord ingly . 7 Inform a senior orthopaedic surgeon of  the injury as soon as possible and make preparations for the surgical phase. Surgical phase In the past an open fracture was considered a contraindication to internal ﬁxation. It is increasingly evident that stable ﬁxation of  the bony injury is very important to prevent deterioration of the soft tissues, allowing recovery and healing. Fracture stabilisation may come in the form of  external ﬁxation or internal ﬁxation with screws/plates/intramedullary nails, de pending on the setting. Summary box 32.7 Special considerations /uni25CF /uni25CF /uni25CF /uni25CF zone of  injury spreading. Thorough debridement of  any con - - taminated or non-vital soft tissue is important. Any loose or devitalised bone fragments should be discarded. Bone defects are easier to deal with than an infected non-union. Soft-tissue reconstruction may involve primary or delayed primary closure of  the wound, or more sophistica ted soft-tissue reconstruction options including microvascular free tissue transfer. Continue intravenous antibiotics until 48 hours after deﬁn - - itive wound closure. -
Osteoporotic fractures in older patients may require
specialised
/f_i
xation techniques with locking screw/plate
technology and injectable bone cement augmentation
Pathological fractures may not heal and require load-bearing
not load-sharing implants
Arthroplasty in suitable patients bypasses the problems of
blood supply and weak bone and allows early full weight-
bearing and return to function
Open fractures require prompt debridement, stabilisation and
adequate soft-tissue cover to prevent infection
Open fractures
Any fracture with an overlying wound should be considered an open fracture. The term previously used was a compound fracture. Open fractures require particular mention because adequate stabilisation of  the bony injury and appropriate management of  the soft-tissue injury are paramount to ensure a good outcome with a low complication rate. The treatment of  bone and joint infection is expensive, laborious and time-consuming for the professional as well as the patient. An infected femoral shaft fracture following intramedullary nailing will typically take 3 years and ﬁve operations to clear the infection and achieve union. The Gustilo and Anderson classiﬁcation of  open fractures is the most frequently used classiﬁcation ( Table 32.2 ). The deﬁnitive grade is determined intraoperatively after thorough debridement. It is not based on size of  wound alone but takes into account sev eral factors; for example, a farmyard or heavily contaminated wound of  under 1 /uni00A0 cm may still be considered a grade III injury . - ould
(b)
(a)
Figure 32.32
Variations in
/f_i
xation technique suited to osteoporotic
bone.
(a)
Norian bone substitute has been injected to support the
lateral tibial plateau in the partial articular fracture.
(b)
A locking plate
in a proximal humerus. The screws are threaded into the plate to make
a
/f_i
xed-angle device.
union, optimise function and avoid infection. The treatment of open fractures should be considered in two phases: the emer gency department presurgical phase and the surgical phase. Presurgical phase 1 Take a photograph to document the severity of  the injury and limit the need for repeated opening of  dressings. (Do not delay steps below unduly .) 2 Assess neurovascular status; if compromised and the frac ture is displaced, quickly remove any macroscopic dirt and reduce the fracture/dislocation. It is not essential to achieve an anatomical reduction; simply remove the pres sure from the soft tissues (make a leg look like a leg and an arm look like an ar m). If  the bone was out of  the skin and is reduced under the skin, then document clearly and inform the surgical team. 3 Once overall alignment is achieved, splint the a ﬀ ected limb; treatment of  an open fracture is treatment of  the soft tissues. 4 Apply a moist saline dressing to the wound. It is accept able to irrigate the wound with saline in the emergency department to remove any macroscopic dirt, but deﬁnitive debridement and washout of  the wound should be under taken in a thea tre environment. 5 Administer intravenous antibiotics according to local protocols. It has been shown that early administration of intravenous antibiotics is one of  the most important steps. A broad-spectrum antibiotic should be chosen covering Gram-positive, Gram-negative and, if  there is severe con tamination, anaerobic organisms. 6 Obtain a tetanus immunisation history and treat accord ingly . 7 Inform a senior orthopaedic surgeon of  the injury as soon as possible and make preparations for the surgical phase. Surgical phase In the past an open fracture was considered a contraindication to internal ﬁxation. It is increasingly evident that stable ﬁxation of  the bony injury is very important to prevent deterioration of the soft tissues, allowing recovery and healing. Fracture stabilisation may come in the form of  external ﬁxation or internal ﬁxation with screws/plates/intramedullary nails, de pending on the setting. Summary box 32.7 Special considerations /uni25CF /uni25CF /uni25CF /uni25CF zone of  injury spreading. Thorough debridement of  any con - - taminated or non-vital soft tissue is important. Any loose or devitalised bone fragments should be discarded. Bone defects are easier to deal with than an infected non-union. Soft-tissue reconstruction may involve primary or delayed primary closure of  the wound, or more sophistica ted soft-tissue reconstruction options including microvascular free tissue transfer. Continue intravenous antibiotics until 48 hours after deﬁn - - itive wound closure. -
Osteoporotic fractures in older patients may require
specialised
/f_i
xation techniques with locking screw/plate
technology and injectable bone cement augmentation
Pathological fractures may not heal and require load-bearing
not load-sharing implants
Arthroplasty in suitable patients bypasses the problems of
blood supply and weak bone and allows early full weight-
bearing and return to function
Open fractures require prompt debridement, stabilisation and
adequate soft-tissue cover to prevent infection
Open fractures
Any fracture with an overlying wound should be considered an open fracture. The term previously used was a compound fracture. Open fractures require particular mention because adequate stabilisation of  the bony injury and appropriate management of  the soft-tissue injury are paramount to ensure a good outcome with a low complication rate. The treatment of  bone and joint infection is expensive, laborious and time-consuming for the professional as well as the patient. An infected femoral shaft fracture following intramedullary nailing will typically take 3 years and ﬁve operations to clear the infection and achieve union. The Gustilo and Anderson classiﬁcation of  open fractures is the most frequently used classiﬁcation ( Table 32.2 ). The deﬁnitive grade is determined intraoperatively after thorough debridement. It is not based on size of  wound alone but takes into account sev eral factors; for example, a farmyard or heavily contaminated wound of  under 1 /uni00A0 cm may still be considered a grade III injury . - ould
(b)
(a)
Figure 32.32
Variations in
/f_i
xation technique suited to osteoporotic
bone.
(a)
Norian bone substitute has been injected to support the
lateral tibial plateau in the partial articular fracture.
(b)
A locking plate
in a proximal humerus. The screws are threaded into the plate to make
a
/f_i
xed-angle device.
union, optimise function and avoid infection. The treatment of open fractures should be considered in two phases: the emer gency department presurgical phase and the surgical phase. Presurgical phase 1 Take a photograph to document the severity of  the injury and limit the need for repeated opening of  dressings. (Do not delay steps below unduly .) 2 Assess neurovascular status; if compromised and the frac ture is displaced, quickly remove any macroscopic dirt and reduce the fracture/dislocation. It is not essential to achieve an anatomical reduction; simply remove the pres sure from the soft tissues (make a leg look like a leg and an arm look like an ar m). If  the bone was out of  the skin and is reduced under the skin, then document clearly and inform the surgical team. 3 Once overall alignment is achieved, splint the a ﬀ ected limb; treatment of  an open fracture is treatment of  the soft tissues. 4 Apply a moist saline dressing to the wound. It is accept able to irrigate the wound with saline in the emergency department to remove any macroscopic dirt, but deﬁnitive debridement and washout of  the wound should be under taken in a thea tre environment. 5 Administer intravenous antibiotics according to local protocols. It has been shown that early administration of intravenous antibiotics is one of  the most important steps. A broad-spectrum antibiotic should be chosen covering Gram-positive, Gram-negative and, if  there is severe con tamination, anaerobic organisms. 6 Obtain a tetanus immunisation history and treat accord ingly . 7 Inform a senior orthopaedic surgeon of  the injury as soon as possible and make preparations for the surgical phase. Surgical phase In the past an open fracture was considered a contraindication to internal ﬁxation. It is increasingly evident that stable ﬁxation of  the bony injury is very important to prevent deterioration of the soft tissues, allowing recovery and healing. Fracture stabilisation may come in the form of  external ﬁxation or internal ﬁxation with screws/plates/intramedullary nails, de pending on the setting. Summary box 32.7 Special considerations /uni25CF /uni25CF /uni25CF /uni25CF zone of  injury spreading. Thorough debridement of  any con - - taminated or non-vital soft tissue is important. Any loose or devitalised bone fragments should be discarded. Bone defects are easier to deal with than an infected non-union. Soft-tissue reconstruction may involve primary or delayed primary closure of  the wound, or more sophistica ted soft-tissue reconstruction options including microvascular free tissue transfer. Continue intravenous antibiotics until 48 hours after deﬁn - - itive wound closure. -
Osteoporotic fractures in older patients may require
specialised
/f_i
xation techniques with locking screw/plate
technology and injectable bone cement augmentation
Pathological fractures may not heal and require load-bearing
not load-sharing implants
Arthroplasty in suitable patients bypasses the problems of
blood supply and weak bone and allows early full weight-
bearing and return to function
Open fractures require prompt debridement, stabilisation and
adequate soft-tissue cover to prevent infection

Osteoporotic fractures
Osteoporotic fractures
Osteoporosis is a condition characterised by low bone mineral density and reduced strength. Osteoporotic bone is liable to fracture with low-energy injuries (e.g. a fall from standing height). Treatment of  lower limb osteoporotic fractures in older patients is challenging. As there may be additional and pre-existing mobility problems, such patients are unable to partially weight-bear and so ﬁxation should be strong enough to allow immediate weight-bearing and to hold the position until union. Locking plate technology improves ﬁxation in osteoporotic bone, and bone void ﬁllers can be utilised ( Figure 32.32 ). Osteoporotic fractures
Osteoporosis is a condition characterised by low bone mineral density and reduced strength. Osteoporotic bone is liable to fracture with low-energy injuries (e.g. a fall from standing height). Treatment of  lower limb osteoporotic fractures in older patients is challenging. As there may be additional and pre-existing mobility problems, such patients are unable to partially weight-bear and so ﬁxation should be strong enough to allow immediate weight-bearing and to hold the position until union. Locking plate technology improves ﬁxation in osteoporotic bone, and bone void ﬁllers can be utilised ( Figure 32.32 ). Osteoporotic fractures
Osteoporosis is a condition characterised by low bone mineral density and reduced strength. Osteoporotic bone is liable to fracture with low-energy injuries (e.g. a fall from standing height). Treatment of  lower limb osteoporotic fractures in older patients is challenging. As there may be additional and pre-existing mobility problems, such patients are unable to partially weight-bear and so ﬁxation should be strong enough to allow immediate weight-bearing and to hold the position until union. Locking plate technology improves ﬁxation in osteoporotic bone, and bone void ﬁllers can be utilised ( Figure 32.32 ).

Patellar fractures
Patellar fractures
Similar to olecranon fractures, undisplaced fractures in which the extensor mechanism is intact can be treated non-operatively . - A simple assessment of this is if the patient can straight leg raise to test the extensor mechanism, but beware of  the patient who is able to ‘cheat’ by using the iliotibial band to internally - rotate the leg to compensate for the deﬁcient extensor - mechanism. Displaced fractures require anatomical reduction of the articular surface and reconstitution of the integrity of the extensor mechanism. The cartilage on the patella is very thick; as such, increased amounts of  displacement compared with other joints may not lead to degeneration. Surgical treatment of  simple displaced fractures can be achieved with two K-wires and ﬁgure-of-eight tension band wiring. Multifragmentary patellar fractures can be ver y challeng - ing. Patellar excision is an option but signiﬁcantly reduces the mechanical advantage of  the extensor apparatus. A tension band construct may be augmented by using circumferential wiring of  the patella. - n, Patellar fractures
Similar to olecranon fractures, undisplaced fractures in which the extensor mechanism is intact can be treated non-operatively . - A simple assessment of this is if the patient can straight leg raise to test the extensor mechanism, but beware of  the patient who is able to ‘cheat’ by using the iliotibial band to internally - rotate the leg to compensate for the deﬁcient extensor - mechanism. Displaced fractures require anatomical reduction of the articular surface and reconstitution of the integrity of the extensor mechanism. The cartilage on the patella is very thick; as such, increased amounts of  displacement compared with other joints may not lead to degeneration. Surgical treatment of  simple displaced fractures can be achieved with two K-wires and ﬁgure-of-eight tension band wiring. Multifragmentary patellar fractures can be ver y challeng - ing. Patellar excision is an option but signiﬁcantly reduces the mechanical advantage of  the extensor apparatus. A tension band construct may be augmented by using circumferential wiring of  the patella. - n, Patellar fractures
Similar to olecranon fractures, undisplaced fractures in which the extensor mechanism is intact can be treated non-operatively . - A simple assessment of this is if the patient can straight leg raise to test the extensor mechanism, but beware of  the patient who is able to ‘cheat’ by using the iliotibial band to internally - rotate the leg to compensate for the deﬁcient extensor - mechanism. Displaced fractures require anatomical reduction of the articular surface and reconstitution of the integrity of the extensor mechanism. The cartilage on the patella is very thick; as such, increased amounts of  displacement compared with other joints may not lead to degeneration. Surgical treatment of  simple displaced fractures can be achieved with two K-wires and ﬁgure-of-eight tension band wiring. Multifragmentary patellar fractures can be ver y challeng - ing. Patellar excision is an option but signiﬁcantly reduces the mechanical advantage of  the extensor apparatus. A tension band construct may be augmented by using circumferential wiring of  the patella. - n,

Pathological fractures
Pathological fractures
When abnormal bone fails under normal load this is referred to as a pathological fracture. Depending on the cause of  the pathological fracture the bone may not heal and consideration should be given to a load-bearing device not load-sharing. If involving the joint surface or close to the joint surface, the a ﬀ ected area may be excised en bloc and a joint replacement performed. The bone may be weakened by a primary bone tumour, secondary metastatic deposits, haematological malignancy (myeloma, lymphoma, leukaemia), osteomyelitis and meta bolic bone disease (osteomalacia, Paget’s disease, osteoporosis). A pathological fracture should be suspected if  the history is not consistent with the severity of  the injury . The patient may give a history of  low-energy injury that normally w not cause a fracture. If  a pathological fracture is suspected, the cause should be actively sought. Where a primary bone tumour is suspected, treatment should be planned to prevent disseminating the disease (see Chapter 42 ). In patients with metastatic bone disease, the primary source should be sought if  multiple metastatic deposits are identiﬁed. If  life expectancy is poor, then stabilisation with a load-bearing device may be considered. If an isolated metastasis is identiﬁed Sir James Paget , 1814–1899, surgeon, St Bartholomew’s Hospital, London, UK. more aggressive curative approach may be taken with en bloc excision of  the primary and the isolated secondary de posit. If  a metastatic deposit is identiﬁed prior to fracture, pro - phylactic ﬁxation should be considered if  impending fracture is likely . Prophylactic stabilisation with a load-bearing device is once again advocated. If life expectancy is good and the deposit periarticular, an en bloc e xcision and joint arthroplasty may be considered to optimise return to near normal function as soon as possible. Pathological fractures
When abnormal bone fails under normal load this is referred to as a pathological fracture. Depending on the cause of  the pathological fracture the bone may not heal and consideration should be given to a load-bearing device not load-sharing. If involving the joint surface or close to the joint surface, the a ﬀ ected area may be excised en bloc and a joint replacement performed. The bone may be weakened by a primary bone tumour, secondary metastatic deposits, haematological malignancy (myeloma, lymphoma, leukaemia), osteomyelitis and meta bolic bone disease (osteomalacia, Paget’s disease, osteoporosis). A pathological fracture should be suspected if  the history is not consistent with the severity of  the injury . The patient may give a history of  low-energy injury that normally w not cause a fracture. If  a pathological fracture is suspected, the cause should be actively sought. Where a primary bone tumour is suspected, treatment should be planned to prevent disseminating the disease (see Chapter 42 ). In patients with metastatic bone disease, the primary source should be sought if  multiple metastatic deposits are identiﬁed. If  life expectancy is poor, then stabilisation with a load-bearing device may be considered. If an isolated metastasis is identiﬁed Sir James Paget , 1814–1899, surgeon, St Bartholomew’s Hospital, London, UK. more aggressive curative approach may be taken with en bloc excision of  the primary and the isolated secondary de posit. If  a metastatic deposit is identiﬁed prior to fracture, pro - phylactic ﬁxation should be considered if  impending fracture is likely . Prophylactic stabilisation with a load-bearing device is once again advocated. If life expectancy is good and the deposit periarticular, an en bloc e xcision and joint arthroplasty may be considered to optimise return to near normal function as soon as possible. Pathological fractures
When abnormal bone fails under normal load this is referred to as a pathological fracture. Depending on the cause of  the pathological fracture the bone may not heal and consideration should be given to a load-bearing device not load-sharing. If involving the joint surface or close to the joint surface, the a ﬀ ected area may be excised en bloc and a joint replacement performed. The bone may be weakened by a primary bone tumour, secondary metastatic deposits, haematological malignancy (myeloma, lymphoma, leukaemia), osteomyelitis and meta bolic bone disease (osteomalacia, Paget’s disease, osteoporosis). A pathological fracture should be suspected if  the history is not consistent with the severity of  the injury . The patient may give a history of  low-energy injury that normally w not cause a fracture. If  a pathological fracture is suspected, the cause should be actively sought. Where a primary bone tumour is suspected, treatment should be planned to prevent disseminating the disease (see Chapter 42 ). In patients with metastatic bone disease, the primary source should be sought if  multiple metastatic deposits are identiﬁed. If  life expectancy is poor, then stabilisation with a load-bearing device may be considered. If an isolated metastasis is identiﬁed Sir James Paget , 1814–1899, surgeon, St Bartholomew’s Hospital, London, UK. more aggressive curative approach may be taken with en bloc excision of  the primary and the isolated secondary de posit. If  a metastatic deposit is identiﬁed prior to fracture, pro - phylactic ﬁxation should be considered if  impending fracture is likely . Prophylactic stabilisation with a load-bearing device is once again advocated. If life expectancy is good and the deposit periarticular, an en bloc e xcision and joint arthroplasty may be considered to optimise return to near normal function as soon as possible.

Peripheral nerve injury
Peripheral nerve injury
Seddon classiﬁed nerve injuries into neurapraxia, axonotmesis and neurotmesis: /uni25CF Neurapraxia – no loss of  nerve sheath continuity or periph eral Wallerian degeneration. If  the pressure is removed from the nerve, recovery potential is good but may take months. /uni25CF Axonotmesis – nerve sheath remains intact, with internal nerve ﬁbre damage and associated Wallerian degener ation. The neural tube (endoneurium) can guide the re generating nerve ﬁbres to their target. Good potential for recovery; nerve ﬁbre regrowth is at 1 /uni00A0 mm per day . /uni25CF Neurotmesis – complete division of  the nerve, nerve sheath and nerve ﬁbre. Functionally poor outcome without surgi cal intervention to restore continuity of  the nerve sheath. Although the Seddon classiﬁcation is useful in understand ing the pathoanatomy , the critical discriminator in deﬁning recovery , and need for possible surgical intervention, is the presence or lack of  continuity of  the enveloping nerve shea Peripheral nerve injury
Seddon classiﬁed nerve injuries into neurapraxia, axonotmesis and neurotmesis: /uni25CF Neurapraxia – no loss of  nerve sheath continuity or periph eral Wallerian degeneration. If  the pressure is removed from the nerve, recovery potential is good but may take months. /uni25CF Axonotmesis – nerve sheath remains intact, with internal nerve ﬁbre damage and associated Wallerian degener ation. The neural tube (endoneurium) can guide the re generating nerve ﬁbres to their target. Good potential for recovery; nerve ﬁbre regrowth is at 1 /uni00A0 mm per day . /uni25CF Neurotmesis – complete division of  the nerve, nerve sheath and nerve ﬁbre. Functionally poor outcome without surgi cal intervention to restore continuity of  the nerve sheath. Although the Seddon classiﬁcation is useful in understand ing the pathoanatomy , the critical discriminator in deﬁning recovery , and need for possible surgical intervention, is the presence or lack of  continuity of  the enveloping nerve shea Peripheral nerve injury
Seddon classiﬁed nerve injuries into neurapraxia, axonotmesis and neurotmesis: /uni25CF Neurapraxia – no loss of  nerve sheath continuity or periph eral Wallerian degeneration. If  the pressure is removed from the nerve, recovery potential is good but may take months. /uni25CF Axonotmesis – nerve sheath remains intact, with internal nerve ﬁbre damage and associated Wallerian degener ation. The neural tube (endoneurium) can guide the re generating nerve ﬁbres to their target. Good potential for recovery; nerve ﬁbre regrowth is at 1 /uni00A0 mm per day . /uni25CF Neurotmesis – complete division of  the nerve, nerve sheath and nerve ﬁbre. Functionally poor outcome without surgi cal intervention to restore continuity of  the nerve sheath. Although the Seddon classiﬁcation is useful in understand ing the pathoanatomy , the critical discriminator in deﬁning recovery , and need for possible surgical intervention, is the presence or lack of  continuity of  the enveloping nerve shea

Proximal femoral fractures
Proximal femoral fractures
The blood supply to the femoral head is a prime consideration in treating femoral neck fractures. The blood supply comes via the hip capsule and although vascular anatomy is variable - it is chieﬂy through the medial and lateral branches of  the deep circumﬂex femoral artery in addition to the occasionally - redundant artery of  the ligamentum teres (a branch of  the obturator artery). The joint capsule anteriorly inserts along the intertrochanteric line and posteriorly half-way along the femoral neck. Fractures proximal to the hip capsule are intracapsular and those distal to the capsule are extracapsular fractures. Proximal femoral fractures
The blood supply to the femoral head is a prime consideration in treating femoral neck fractures. The blood supply comes via the hip capsule and although vascular anatomy is variable - it is chieﬂy through the medial and lateral branches of  the deep circumﬂex femoral artery in addition to the occasionally - redundant artery of  the ligamentum teres (a branch of  the obturator artery). The joint capsule anteriorly inserts along the intertrochanteric line and posteriorly half-way along the femoral neck. Fractures proximal to the hip capsule are intracapsular and those distal to the capsule are extracapsular fractures. Proximal femoral fractures
The blood supply to the femoral head is a prime consideration in treating femoral neck fractures. The blood supply comes via the hip capsule and although vascular anatomy is variable - it is chieﬂy through the medial and lateral branches of  the deep circumﬂex femoral artery in addition to the occasionally - redundant artery of  the ligamentum teres (a branch of  the obturator artery). The joint capsule anteriorly inserts along the intertrochanteric line and posteriorly half-way along the femoral neck. Fractures proximal to the hip capsule are intracapsular and those distal to the capsule are extracapsular fractures.

Reduce
Reduce
The ﬁrst thing to consider is the degree of  displacement of the fracture fragments. It is useful to ask the following question: if the bone were to heal in this position, would it be compatible with optimum function in the short and long term? In general, fractures involving the articular joint surface - need to be reduced perfectly back to their original anatom - ical position, to restore normal joint movement in the short term and avoid degenerative joint disease in the long term – intra-articular fracture = anatomical reduction . /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Fractures that do not involve the joint surface generally require restoration of  mechanical alignment of  the joints above and below . The fracture fragments do not need to be reduced perfectly . Focus on acceptable alignment, length and rotation – extra-articular fracture = mechanical alignment In children an extra-articular fracture has the ability to remodel, and therefore an increased degree of  displacement can be accepted. If  a fracture requires reduction, it can be reduced open or closed. A closed reduction is wher e the bones are manipulated and moved without exposing the bone. Often the best way to reduce a fracture is to reverse the sequence of  injur y , without tearing or further damaging the intact soft tissues and perios teum. On occasion this may mean exaggerating the deformity ( Figure 32.13 ). Open reduction is utilised if  an acceptable closed reduction is not achieved or likely to succeed. A combination of  closed and open methods can be used to reduce a fracture. Care should be taken during an open r eduction not to unduly devit alise the fracture fragments by stripping intact periosteum. A balance between maintaining a blood supply to the fracture fragments (biolog y) and achieving anatomical reduction needs to be maintained. Adequacy of  reduction is complex and depends on many factors. If  intra-articular, the joint surface in volved needs to be considered. By way of  an example, 2 /uni00A0 mm of  residual displace ment of  the articular surface ma y be acceptable in the patella and tibial plateau and may be acceptable in fractures involving the distal radius, but is not acceptable in the condylar joints of  the ﬁngers. In general consider the relativ e thickness of  the articular surface involved. On occasion consideration of  how you intend to sub sequently hold the fracture may a ﬀ ect the primary form of reduction.
Bene
/f_i
ts
Risks
Pain relief
Anaesthesia
Prevention of infection
Introduction of infection
Restoration of anatomy
Damage to soft tissues and
neurovascular structures
Early movement of the limb
Early movement of the
Devitalising bone
patient
Need for implant removal
Improved function
Financial cost (cost of
treatment)
Reduced risk of secondary
arthritis
Financial cost (time off work)
Reduce
The ﬁrst thing to consider is the degree of  displacement of the fracture fragments. It is useful to ask the following question: if the bone were to heal in this position, would it be compatible with optimum function in the short and long term? In general, fractures involving the articular joint surface - need to be reduced perfectly back to their original anatom - ical position, to restore normal joint movement in the short term and avoid degenerative joint disease in the long term – intra-articular fracture = anatomical reduction . /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Fractures that do not involve the joint surface generally require restoration of  mechanical alignment of  the joints above and below . The fracture fragments do not need to be reduced perfectly . Focus on acceptable alignment, length and rotation – extra-articular fracture = mechanical alignment In children an extra-articular fracture has the ability to remodel, and therefore an increased degree of  displacement can be accepted. If  a fracture requires reduction, it can be reduced open or closed. A closed reduction is wher e the bones are manipulated and moved without exposing the bone. Often the best way to reduce a fracture is to reverse the sequence of  injur y , without tearing or further damaging the intact soft tissues and perios teum. On occasion this may mean exaggerating the deformity ( Figure 32.13 ). Open reduction is utilised if  an acceptable closed reduction is not achieved or likely to succeed. A combination of  closed and open methods can be used to reduce a fracture. Care should be taken during an open r eduction not to unduly devit alise the fracture fragments by stripping intact periosteum. A balance between maintaining a blood supply to the fracture fragments (biolog y) and achieving anatomical reduction needs to be maintained. Adequacy of  reduction is complex and depends on many factors. If  intra-articular, the joint surface in volved needs to be considered. By way of  an example, 2 /uni00A0 mm of  residual displace ment of  the articular surface ma y be acceptable in the patella and tibial plateau and may be acceptable in fractures involving the distal radius, but is not acceptable in the condylar joints of  the ﬁngers. In general consider the relativ e thickness of  the articular surface involved. On occasion consideration of  how you intend to sub sequently hold the fracture may a ﬀ ect the primary form of reduction.
Bene
/f_i
ts
Risks
Pain relief
Anaesthesia
Prevention of infection
Introduction of infection
Restoration of anatomy
Damage to soft tissues and
neurovascular structures
Early movement of the limb
Early movement of the
Devitalising bone
patient
Need for implant removal
Improved function
Financial cost (cost of
treatment)
Reduced risk of secondary
arthritis
Financial cost (time off work)
Reduce
The ﬁrst thing to consider is the degree of  displacement of the fracture fragments. It is useful to ask the following question: if the bone were to heal in this position, would it be compatible with optimum function in the short and long term? In general, fractures involving the articular joint surface - need to be reduced perfectly back to their original anatom - ical position, to restore normal joint movement in the short term and avoid degenerative joint disease in the long term – intra-articular fracture = anatomical reduction . /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Fractures that do not involve the joint surface generally require restoration of  mechanical alignment of  the joints above and below . The fracture fragments do not need to be reduced perfectly . Focus on acceptable alignment, length and rotation – extra-articular fracture = mechanical alignment In children an extra-articular fracture has the ability to remodel, and therefore an increased degree of  displacement can be accepted. If  a fracture requires reduction, it can be reduced open or closed. A closed reduction is wher e the bones are manipulated and moved without exposing the bone. Often the best way to reduce a fracture is to reverse the sequence of  injur y , without tearing or further damaging the intact soft tissues and perios teum. On occasion this may mean exaggerating the deformity ( Figure 32.13 ). Open reduction is utilised if  an acceptable closed reduction is not achieved or likely to succeed. A combination of  closed and open methods can be used to reduce a fracture. Care should be taken during an open r eduction not to unduly devit alise the fracture fragments by stripping intact periosteum. A balance between maintaining a blood supply to the fracture fragments (biolog y) and achieving anatomical reduction needs to be maintained. Adequacy of  reduction is complex and depends on many factors. If  intra-articular, the joint surface in volved needs to be considered. By way of  an example, 2 /uni00A0 mm of  residual displace ment of  the articular surface ma y be acceptable in the patella and tibial plateau and may be acceptable in fractures involving the distal radius, but is not acceptable in the condylar joints of  the ﬁngers. In general consider the relativ e thickness of  the articular surface involved. On occasion consideration of  how you intend to sub sequently hold the fracture may a ﬀ ect the primary form of reduction.
Bene
/f_i
ts
Risks
Pain relief
Anaesthesia
Prevention of infection
Introduction of infection
Restoration of anatomy
Damage to soft tissues and
neurovascular structures
Early movement of the limb
Early movement of the
Devitalising bone
patient
Need for implant removal
Improved function
Financial cost (cost of
treatment)
Reduced risk of secondary
arthritis
Financial cost (time off work)

SPECIAL CONSIDERATIONS
SPECIAL CONSIDERATIONS
Special consideration needs to be given to osteoporotic and pathological fractures, for example the ability to hold the frac ture until union. Furthermore, open fractures require urgent appropriate treatment to ensure bone healing in the absence of  infection. SPECIAL CONSIDERATIONS
Special consideration needs to be given to osteoporotic and pathological fractures, for example the ability to hold the frac ture until union. Furthermore, open fractures require urgent appropriate treatment to ensure bone healing in the absence of  infection. SPECIAL CONSIDERATIONS
Special consideration needs to be given to osteoporotic and pathological fractures, for example the ability to hold the frac ture until union. Furthermore, open fractures require urgent appropriate treatment to ensure bone healing in the absence of  infection.

SPECIFIC PAEDIATRIC INJURIES Distal radial fractur
SPECIFIC PAEDIATRIC INJURIES Distal radial fractures
Fractures of  the distal radius are very common in children. The bone either fails at the physis, leading to Salter–Harris type 2 fractures of  the distal radius, or the metaphysis fails. The treatment principle of physeal fractures is to achieve an anatomical reduction. This can often be achieved with closed manipulation and the fracture held in position until healing with a below-elbow plaster cast. Growth arrest is rare after physeal fractures of  the distal radius. close attention ( Figure 32.28 ). In most cases an acceptable closed reduction can be achieved, but holding the distal frag - ment in an acceptable position can be challenging with cast immobilisation. Brachioradialis, w hich is attached to the radial - styloid, is a continual deforming force. If  non-operative treat - ment using a cast application is chosen, the position should be checked with radiographs weekly for the ﬁrst 3 weeks; if re-displacement occurs, repeat manipulation and K-wire ﬁxa - tion may be required.
(a)
(b)
Figure 32.28
10-year-old child showing a dorsally angulated metaphyseal
fracture of the radius and undisplaced fracture of the ulna.
injury was treated with closed manipulation and cast application.
Eight weeks’ postinjury radiograph out of the cast. The fracture
is united, with residual 11° dorsal angulation.
the wrist following repeat injury 2 years later at age 12, showing
complete remodelling. No residual deformity.
SPECIFIC PAEDIATRIC INJURIES Distal radial fractures
Fractures of  the distal radius are very common in children. The bone either fails at the physis, leading to Salter–Harris type 2 fractures of  the distal radius, or the metaphysis fails. The treatment principle of physeal fractures is to achieve an anatomical reduction. This can often be achieved with closed manipulation and the fracture held in position until healing with a below-elbow plaster cast. Growth arrest is rare after physeal fractures of  the distal radius. close attention ( Figure 32.28 ). In most cases an acceptable closed reduction can be achieved, but holding the distal frag - ment in an acceptable position can be challenging with cast immobilisation. Brachioradialis, w hich is attached to the radial - styloid, is a continual deforming force. If  non-operative treat - ment using a cast application is chosen, the position should be checked with radiographs weekly for the ﬁrst 3 weeks; if re-displacement occurs, repeat manipulation and K-wire ﬁxa - tion may be required.
(a)
(b)
Figure 32.28
10-year-old child showing a dorsally angulated metaphyseal
fracture of the radius and undisplaced fracture of the ulna.
injury was treated with closed manipulation and cast application.
Eight weeks’ postinjury radiograph out of the cast. The fracture
is united, with residual 11° dorsal angulation.
the wrist following repeat injury 2 years later at age 12, showing
complete remodelling. No residual deformity.

SPECIFIC PAEDIATRIC INJURIES Distal radial fractures
SPECIFIC PAEDIATRIC INJURIES Distal radial fractures
Fractures of  the distal radius are very common in children. The bone either fails at the physis, leading to Salter–Harris type 2 fractures of  the distal radius, or the metaphysis fails. The treatment principle of physeal fractures is to achieve an anatomical reduction. This can often be achieved with closed manipulation and the fracture held in position until healing with a below-elbow plaster cast. Growth arrest is rare after physeal fractures of  the distal radius. close attention ( Figure 32.28 ). In most cases an acceptable closed reduction can be achieved, but holding the distal frag - ment in an acceptable position can be challenging with cast immobilisation. Brachioradialis, w hich is attached to the radial - styloid, is a continual deforming force. If  non-operative treat - ment using a cast application is chosen, the position should be checked with radiographs weekly for the ﬁrst 3 weeks; if re-displacement occurs, repeat manipulation and K-wire ﬁxa - tion may be required.
(a)
(b)
Figure 32.28
10-year-old child showing a dorsally angulated metaphyseal
fracture of the radius and undisplaced fracture of the ulna.
injury was treated with closed manipulation and cast application.
Eight weeks’ postinjury radiograph out of the cast. The fracture
is united, with residual 11° dorsal angulation.
the wrist following repeat injury 2 years later at age 12, showing
complete remodelling. No residual deformity.

Slipped upper femoral epiphysis
Slipped upper femoral epiphysis
A slipped upper femoral epiphysis classically occurs in a child approaching puberty . It is easily missed as symptoms may be mild and the predominant symptom may be knee pain referred from the hip. A history of  trauma may be o ﬀ ered and the child may limp. Examination of  the limb reveals a hip that ﬂexes into exter - - nal rotation. Radiographs should include a good lateral view of the femoral head and neck ( Figure 32.30 ). If the radio - graphs are normal, consider an MRI, looking f or a preslip; if found, consider prophylactic ﬁxation. If treated in the early stages, the prognosis is very good. A severely displaced slipped upper femoral epiphysis might lead to avascular necrosis of  the femoral head and chondrolysis. This is a very di ﬃ cult condi - tion to treat e ﬀ ectively in young patients. Slipped upper femoral epiphysis
A slipped upper femoral epiphysis classically occurs in a child approaching puberty . It is easily missed as symptoms may be mild and the predominant symptom may be knee pain referred from the hip. A history of  trauma may be o ﬀ ered and the child may limp. Examination of  the limb reveals a hip that ﬂexes into exter - - nal rotation. Radiographs should include a good lateral view of the femoral head and neck ( Figure 32.30 ). If the radio - graphs are normal, consider an MRI, looking f or a preslip; if found, consider prophylactic ﬁxation. If treated in the early stages, the prognosis is very good. A severely displaced slipped upper femoral epiphysis might lead to avascular necrosis of  the femoral head and chondrolysis. This is a very di ﬃ cult condi - tion to treat e ﬀ ectively in young patients. Slipped upper femoral epiphysis
A slipped upper femoral epiphysis classically occurs in a child approaching puberty . It is easily missed as symptoms may be mild and the predominant symptom may be knee pain referred from the hip. A history of  trauma may be o ﬀ ered and the child may limp. Examination of  the limb reveals a hip that ﬂexes into exter - - nal rotation. Radiographs should include a good lateral view of the femoral head and neck ( Figure 32.30 ). If the radio - graphs are normal, consider an MRI, looking f or a preslip; if found, consider prophylactic ﬁxation. If treated in the early stages, the prognosis is very good. A severely displaced slipped upper femoral epiphysis might lead to avascular necrosis of  the femoral head and chondrolysis. This is a very di ﬃ cult condi - tion to treat e ﬀ ectively in young patients.

TO TOE) Scaphoid fracture
TO TOE) Scaphoid fracture
The blood supply to the scaphoid enters distally and supplies the scaphoid in a retrograde fashion. As such, a displaced waist of  scaphoid fracture interrupts the blood supply to the proximal pole, leading to avascular necrosis. An undisplaced fracture of  the scaphoid may not be visible on the initial radiographs. If a fracture is not evident on the initial radiographs and the patient is tender in the anatomical snu ﬀ box following a fall on the outstretched hand, special scaphoid view radiographs should be requested ( Figure 32.21 ). If  a fracture is not evident on the initial radiographs and the patient remains tender in the anatomical snu ﬀ box, then treat as a suspected scaphoid fracture until a fracture is actively excluded. The standard pr otocol of a suspected scaphoid frac ture is to immobilise the wrist and examine again 10–14 days later. If  tenderness remains, repeat the scaphoid views. If  facili ties and resources allow , an earlier diagnosis ma y be made with a bone scan, MRI or CT . Undisplaced fractures can be treated non-operatively in a below-elbow cast. It is not necessary to include the thumb as a routine. In displaced or unstable fractures (>1 /uni00A0 mm) consid eration should be given to open r eduction and rigid ﬁxation with a headless compression screw . Complications of scaphoid fractures include: non-union, avascular necrosis, malunion and carpal instability . TO TOE) Scaphoid fracture
The blood supply to the scaphoid enters distally and supplies the scaphoid in a retrograde fashion. As such, a displaced waist of  scaphoid fracture interrupts the blood supply to the proximal pole, leading to avascular necrosis. An undisplaced fracture of  the scaphoid may not be visible on the initial radiographs. If a fracture is not evident on the initial radiographs and the patient is tender in the anatomical snu ﬀ box following a fall on the outstretched hand, special scaphoid view radiographs should be requested ( Figure 32.21 ). If  a fracture is not evident on the initial radiographs and the patient remains tender in the anatomical snu ﬀ box, then treat as a suspected scaphoid fracture until a fracture is actively excluded. The standard pr otocol of a suspected scaphoid frac ture is to immobilise the wrist and examine again 10–14 days later. If  tenderness remains, repeat the scaphoid views. If  facili ties and resources allow , an earlier diagnosis ma y be made with a bone scan, MRI or CT . Undisplaced fractures can be treated non-operatively in a below-elbow cast. It is not necessary to include the thumb as a routine. In displaced or unstable fractures (>1 /uni00A0 mm) consid eration should be given to open r eduction and rigid ﬁxation with a headless compression screw . Complications of scaphoid fractures include: non-union, avascular necrosis, malunion and carpal instability . TO TOE) Scaphoid fracture
The blood supply to the scaphoid enters distally and supplies the scaphoid in a retrograde fashion. As such, a displaced waist of  scaphoid fracture interrupts the blood supply to the proximal pole, leading to avascular necrosis. An undisplaced fracture of  the scaphoid may not be visible on the initial radiographs. If a fracture is not evident on the initial radiographs and the patient is tender in the anatomical snu ﬀ box following a fall on the outstretched hand, special scaphoid view radiographs should be requested ( Figure 32.21 ). If  a fracture is not evident on the initial radiographs and the patient remains tender in the anatomical snu ﬀ box, then treat as a suspected scaphoid fracture until a fracture is actively excluded. The standard pr otocol of a suspected scaphoid frac ture is to immobilise the wrist and examine again 10–14 days later. If  tenderness remains, repeat the scaphoid views. If  facili ties and resources allow , an earlier diagnosis ma y be made with a bone scan, MRI or CT . Undisplaced fractures can be treated non-operatively in a below-elbow cast. It is not necessary to include the thumb as a routine. In displaced or unstable fractures (>1 /uni00A0 mm) consid eration should be given to open r eduction and rigid ﬁxation with a headless compression screw . Complications of scaphoid fractures include: non-union, avascular necrosis, malunion and carpal instability .

TREATMENT BY FRACTURE LOCATION
TREATMENT BY FRACTURE LOCATION
In general, the principles of  treatment described above are dependent on the fracture location: diaphyseal, metaphyseal and intra-articular. Table 32.11 outlines some indications for operative stabi - lisation. TREATMENT BY FRACTURE LOCATION
In general, the principles of  treatment described above are dependent on the fracture location: diaphyseal, metaphyseal and intra-articular. Table 32.11 outlines some indications for operative stabi - lisation. TREATMENT BY FRACTURE LOCATION
In general, the principles of  treatment described above are dependent on the fracture location: diaphyseal, metaphyseal and intra-articular. Table 32.11 outlines some indications for operative stabi - lisation.

TREATMENT OF FRACTURES IN THE SKELETALL Y IMMATURE
TREATMENT OF FRACTURES IN THE SKELETALL Y IMMATURE
The treatment principles that were described for the adult are equally applicable to the child (i.e. reduce, hold, heal, rehabilitate). A major di ﬀ erence to consider is that in extra-articular fractures there is a remodelling potential, which means that increased degrees of  deformity may be accepted. Remodelling happens best in the plane of  the joint and the closer the injur y rowth plate. Rotational and joint surface remodelling is to the g are poor. Fractures occurring near the site of  greatest longi - tudinal growth will remodel the most (e.g. fractures around the distal femur have a greater remodelling potential than the proximal femur). The younger the patient, the greater the remodelling potential. Signiﬁcant r emodelling essentially ceases when the growth plates have closed. - A further di ﬀ erence is that paediatric fractures heal more rapidly and, as such, do not need to be held as long as in the adult counterpart. Similarly , ﬁxation does not need to be as rigid, as fracture union is more rapid. Growth plate injuries require special mention ( Figure 32.12 ). In general, gro wth plate injuries should be anatomically reduced to minimise the potential for growth disturbance. Howev er, in the process of  reducing the fracture, further injury to the growth plate should be avoided. Repeated manipulation of  physeal injuries should be avoided. Injury to the perichondral ring and placing metal -
Talus
(d)
Talus
(c, d)
Intraoperative views of the reconstruc
avoided. If  ﬁxation necessitates crossing the physis, consider limited damage by using the smallest smooth K-wires with a single pass in the middle of  the physis if  possible. The paediatric periosteum is often thick and very strong; this needs to be considered when reducing the fracture, requir ing an exaggeration of  the deformity and pushing the fracture back into place instead of  just applying longitudinal traction. The periosteal hinge should be preserv ed as it also allows for better holding of  the fracture if  it remains intact, as pre viously described ( Figure 32.12 ). Always consider the possibility of  non-accidental injury , as discussed in Chapters 26 and 44 . TREATMENT OF FRACTURES IN THE SKELETALL Y IMMATURE
The treatment principles that were described for the adult are equally applicable to the child (i.e. reduce, hold, heal, rehabilitate). A major di ﬀ erence to consider is that in extra-articular fractures there is a remodelling potential, which means that increased degrees of  deformity may be accepted. Remodelling happens best in the plane of  the joint and the closer the injur y rowth plate. Rotational and joint surface remodelling is to the g are poor. Fractures occurring near the site of  greatest longi - tudinal growth will remodel the most (e.g. fractures around the distal femur have a greater remodelling potential than the proximal femur). The younger the patient, the greater the remodelling potential. Signiﬁcant r emodelling essentially ceases when the growth plates have closed. - A further di ﬀ erence is that paediatric fractures heal more rapidly and, as such, do not need to be held as long as in the adult counterpart. Similarly , ﬁxation does not need to be as rigid, as fracture union is more rapid. Growth plate injuries require special mention ( Figure 32.12 ). In general, gro wth plate injuries should be anatomically reduced to minimise the potential for growth disturbance. Howev er, in the process of  reducing the fracture, further injury to the growth plate should be avoided. Repeated manipulation of  physeal injuries should be avoided. Injury to the perichondral ring and placing metal -
Talus
(d)
Talus
(c, d)
Intraoperative views of the reconstruc
avoided. If  ﬁxation necessitates crossing the physis, consider limited damage by using the smallest smooth K-wires with a single pass in the middle of  the physis if  possible. The paediatric periosteum is often thick and very strong; this needs to be considered when reducing the fracture, requir ing an exaggeration of  the deformity and pushing the fracture back into place instead of  just applying longitudinal traction. The periosteal hinge should be preserv ed as it also allows for better holding of  the fracture if  it remains intact, as pre viously described ( Figure 32.12 ). Always consider the possibility of  non-accidental injury , as discussed in Chapters 26 and 44 . TREATMENT OF FRACTURES IN THE SKELETALL Y IMMATURE
The treatment principles that were described for the adult are equally applicable to the child (i.e. reduce, hold, heal, rehabilitate). A major di ﬀ erence to consider is that in extra-articular fractures there is a remodelling potential, which means that increased degrees of  deformity may be accepted. Remodelling happens best in the plane of  the joint and the closer the injur y rowth plate. Rotational and joint surface remodelling is to the g are poor. Fractures occurring near the site of  greatest longi - tudinal growth will remodel the most (e.g. fractures around the distal femur have a greater remodelling potential than the proximal femur). The younger the patient, the greater the remodelling potential. Signiﬁcant r emodelling essentially ceases when the growth plates have closed. - A further di ﬀ erence is that paediatric fractures heal more rapidly and, as such, do not need to be held as long as in the adult counterpart. Similarly , ﬁxation does not need to be as rigid, as fracture union is more rapid. Growth plate injuries require special mention ( Figure 32.12 ). In general, gro wth plate injuries should be anatomically reduced to minimise the potential for growth disturbance. Howev er, in the process of  reducing the fracture, further injury to the growth plate should be avoided. Repeated manipulation of  physeal injuries should be avoided. Injury to the perichondral ring and placing metal -
Talus
(d)
Talus
(c, d)
Intraoperative views of the reconstruc
avoided. If  ﬁxation necessitates crossing the physis, consider limited damage by using the smallest smooth K-wires with a single pass in the middle of  the physis if  possible. The paediatric periosteum is often thick and very strong; this needs to be considered when reducing the fracture, requir ing an exaggeration of  the deformity and pushing the fracture back into place instead of  just applying longitudinal traction. The periosteal hinge should be preserv ed as it also allows for better holding of  the fracture if  it remains intact, as pre viously described ( Figure 32.12 ). Always consider the possibility of  non-accidental injury , as discussed in Chapters 26 and 44 .

TREATMENT
TREATMENT
The main principle of  extremity fracture management builds on the classical concept of  reduction and stabilisation of  the fracture. Treatment can be considered under the following headings (see Apley’s system of orthopaedics and frac - tures [Further reading] ): /uni25CF reduce; /uni25CF hold; /uni25CF heal; /uni25CF rehabilitate. The main objective of  any treatment is to return the patient - to normal function as soon and as safely as possible. Broadly speaking, treatment may be operative or non-operative, with di ﬀ ering risks and beneﬁts ( Table 32.3 ). TREATMENT
The main principle of  extremity fracture management builds on the classical concept of  reduction and stabilisation of  the fracture. Treatment can be considered under the following headings (see Apley’s system of orthopaedics and frac - tures [Further reading] ): /uni25CF reduce; /uni25CF hold; /uni25CF heal; /uni25CF rehabilitate. The main objective of  any treatment is to return the patient - to normal function as soon and as safely as possible. Broadly speaking, treatment may be operative or non-operative, with di ﬀ ering risks and beneﬁts ( Table 32.3 ). TREATMENT
The main principle of  extremity fracture management builds on the classical concept of  reduction and stabilisation of  the fracture. Treatment can be considered under the following headings (see Apley’s system of orthopaedics and frac - tures [Further reading] ): /uni25CF reduce; /uni25CF hold; /uni25CF heal; /uni25CF rehabilitate. The main objective of  any treatment is to return the patient - to normal function as soon and as safely as possible. Broadly speaking, treatment may be operative or non-operative, with di ﬀ ering risks and beneﬁts ( Table 32.3 ).

Talus fracture
Talus fracture
The talus consists of  a head, neck and body . The most common injury is a talar neck fracture. This is caused by forced dorsiﬂexion of  the forefoot (aviator’s astragalus). The blood supply to the body of  the talus is interrupted in displaced talar neck fractures. In high-energy injuries the talus can not only be fractured but also dislocated, at either the talonavicular joint, subtalar joint or tibiotalar joint. These are very serious injuries to the foot that can a ﬀ ect the patient’s long-term function through the development of  either degenerative changes or avascular necrosis. To optimise outcome and reduce the possibility of avascular necrosis, anatomical reduction and stable ﬁxation of the talar neck should be performed. Fixation of  the talus to achieve compression can be technically very challenging. An operative issue with talus fractures is that there tends to be comminution that does not allow e ﬀ ective compression of  the fracture fragments together, or when compression is achieved the shape of  the talus is inadvertently altered, thereby a ﬀ ect - ing the shape of  the foot. In addition, the injury to the blood supply from the initial trauma may result in avascular necrosis - of  the talus, non-union and later degeneration between it and the adjacent joints (tibiotalar, talocalcaneal and talonavicular). Talus fracture
The talus consists of  a head, neck and body . The most common injury is a talar neck fracture. This is caused by forced dorsiﬂexion of  the forefoot (aviator’s astragalus). The blood supply to the body of  the talus is interrupted in displaced talar neck fractures. In high-energy injuries the talus can not only be fractured but also dislocated, at either the talonavicular joint, subtalar joint or tibiotalar joint. These are very serious injuries to the foot that can a ﬀ ect the patient’s long-term function through the development of  either degenerative changes or avascular necrosis. To optimise outcome and reduce the possibility of avascular necrosis, anatomical reduction and stable ﬁxation of the talar neck should be performed. Fixation of  the talus to achieve compression can be technically very challenging. An operative issue with talus fractures is that there tends to be comminution that does not allow e ﬀ ective compression of  the fracture fragments together, or when compression is achieved the shape of  the talus is inadvertently altered, thereby a ﬀ ect - ing the shape of  the foot. In addition, the injury to the blood supply from the initial trauma may result in avascular necrosis - of  the talus, non-union and later degeneration between it and the adjacent joints (tibiotalar, talocalcaneal and talonavicular). Talus fracture
The talus consists of  a head, neck and body . The most common injury is a talar neck fracture. This is caused by forced dorsiﬂexion of  the forefoot (aviator’s astragalus). The blood supply to the body of  the talus is interrupted in displaced talar neck fractures. In high-energy injuries the talus can not only be fractured but also dislocated, at either the talonavicular joint, subtalar joint or tibiotalar joint. These are very serious injuries to the foot that can a ﬀ ect the patient’s long-term function through the development of  either degenerative changes or avascular necrosis. To optimise outcome and reduce the possibility of avascular necrosis, anatomical reduction and stable ﬁxation of the talar neck should be performed. Fixation of  the talus to achieve compression can be technically very challenging. An operative issue with talus fractures is that there tends to be comminution that does not allow e ﬀ ective compression of  the fracture fragments together, or when compression is achieved the shape of  the talus is inadvertently altered, thereby a ﬀ ect - ing the shape of  the foot. In addition, the injury to the blood supply from the initial trauma may result in avascular necrosis - of  the talus, non-union and later degeneration between it and the adjacent joints (tibiotalar, talocalcaneal and talonavicular).

Tarsometatarsal (Lisfranc) joint injuries
Tarsometatarsal (Lisfranc) joint injuries
Injuries to the midfoot are associated with signiﬁcant morbidity ranging from a midfoot sprain to complete rupture of the liga - ments connecting the forefoot to the midfoot. Injury classically follows forced plantarﬂexion of  the midfoot. An alternative - mechanism of  injury are crush injuries where the foot is f orced ﬂat by a heavy weight. Lisfranc’s ligament connects the second metatarsal to the medial cuneiform. Poorly treated injuries to the midfoot lead to signiﬁcant morbidity and, if suspected, - a CT of the foot should be undertaken. Treatment options range from closed reduction and plaster cast application to - open reduction and internal ﬁxation. In severe cases primary tarsometatarsal fusion may be considered. Tarsometatarsal (Lisfranc) joint injuries
Injuries to the midfoot are associated with signiﬁcant morbidity ranging from a midfoot sprain to complete rupture of the liga - ments connecting the forefoot to the midfoot. Injury classically follows forced plantarﬂexion of  the midfoot. An alternative - mechanism of  injury are crush injuries where the foot is f orced ﬂat by a heavy weight. Lisfranc’s ligament connects the second metatarsal to the medial cuneiform. Poorly treated injuries to the midfoot lead to signiﬁcant morbidity and, if suspected, - a CT of the foot should be undertaken. Treatment options range from closed reduction and plaster cast application to - open reduction and internal ﬁxation. In severe cases primary tarsometatarsal fusion may be considered. Tarsometatarsal (Lisfranc) joint injuries
Injuries to the midfoot are associated with signiﬁcant morbidity ranging from a midfoot sprain to complete rupture of the liga - ments connecting the forefoot to the midfoot. Injury classically follows forced plantarﬂexion of  the midfoot. An alternative - mechanism of  injury are crush injuries where the foot is f orced ﬂat by a heavy weight. Lisfranc’s ligament connects the second metatarsal to the medial cuneiform. Poorly treated injuries to the midfoot lead to signiﬁcant morbidity and, if suspected, - a CT of the foot should be undertaken. Treatment options range from closed reduction and plaster cast application to - open reduction and internal ﬁxation. In severe cases primary tarsometatarsal fusion may be considered.

Terminology of bone healing after fracture
Terminology of bone healing after fracture
Union The fracture has healed su ﬃ ciently from a clinical perspective to withstand physiological loads, with very little pain and mini mal tenderness at the fracture site. Radiologically a fracture has united when the callus bridges the fracture site. Delayed union This description can be applied to a fracture that is slow to heal and that has not healed in the expected time frame. Non-union This description can be applied to a fracture that has not healed and shows no potential to heal without further intervention. A non-union can also be deﬁned as a fracture that fails to demon strate clinical or radiological improvement over 3 months. In general, you do not describe a fracture as ‘non-union’ until 6 /uni00A0 months after the injury . Stephan M Perren , 1932–2019, Director, AO Research Institute, Davos, Switzerland, 1967–1996. phic, hypertrophic and infected. It is useful to consider certain factor s with regard to the non-union: the biology of  the frac - - ture, the mechanical environment and the host (patient factors such as diabetes and smoking). In an atrophic non-union, the pr oblem is generally a bio - logical one, with a lack of  stimulus or blood supply . A hyper - trophic non-union generally occurs when there is too muc h movement at the fracture site. Consolidation This follows union and demonstrates that the bone has returned to normal strength. Radiologically it is demonstrated by the return of  the normal cortical pattern. Remodelling In children, and to a lesser degree in adults, bone remodels based on the forces passing through it. - Summary box 32.3 - Fracture healing - /uni25CF /uni25CF -
Direct – cortical apposition and absolute stability
Indirect – secondary bone healing, requires some movement
Terminology of bone healing after fracture
Union The fracture has healed su ﬃ ciently from a clinical perspective to withstand physiological loads, with very little pain and mini mal tenderness at the fracture site. Radiologically a fracture has united when the callus bridges the fracture site. Delayed union This description can be applied to a fracture that is slow to heal and that has not healed in the expected time frame. Non-union This description can be applied to a fracture that has not healed and shows no potential to heal without further intervention. A non-union can also be deﬁned as a fracture that fails to demon strate clinical or radiological improvement over 3 months. In general, you do not describe a fracture as ‘non-union’ until 6 /uni00A0 months after the injury . Stephan M Perren , 1932–2019, Director, AO Research Institute, Davos, Switzerland, 1967–1996. phic, hypertrophic and infected. It is useful to consider certain factor s with regard to the non-union: the biology of  the frac - - ture, the mechanical environment and the host (patient factors such as diabetes and smoking). In an atrophic non-union, the pr oblem is generally a bio - logical one, with a lack of  stimulus or blood supply . A hyper - trophic non-union generally occurs when there is too muc h movement at the fracture site. Consolidation This follows union and demonstrates that the bone has returned to normal strength. Radiologically it is demonstrated by the return of  the normal cortical pattern. Remodelling In children, and to a lesser degree in adults, bone remodels based on the forces passing through it. - Summary box 32.3 - Fracture healing - /uni25CF /uni25CF -
Direct – cortical apposition and absolute stability
Indirect – secondary bone healing, requires some movement
Terminology of bone healing after fracture
Union The fracture has healed su ﬃ ciently from a clinical perspective to withstand physiological loads, with very little pain and mini mal tenderness at the fracture site. Radiologically a fracture has united when the callus bridges the fracture site. Delayed union This description can be applied to a fracture that is slow to heal and that has not healed in the expected time frame. Non-union This description can be applied to a fracture that has not healed and shows no potential to heal without further intervention. A non-union can also be deﬁned as a fracture that fails to demon strate clinical or radiological improvement over 3 months. In general, you do not describe a fracture as ‘non-union’ until 6 /uni00A0 months after the injury . Stephan M Perren , 1932–2019, Director, AO Research Institute, Davos, Switzerland, 1967–1996. phic, hypertrophic and infected. It is useful to consider certain factor s with regard to the non-union: the biology of  the frac - - ture, the mechanical environment and the host (patient factors such as diabetes and smoking). In an atrophic non-union, the pr oblem is generally a bio - logical one, with a lack of  stimulus or blood supply . A hyper - trophic non-union generally occurs when there is too muc h movement at the fracture site. Consolidation This follows union and demonstrates that the bone has returned to normal strength. Radiologically it is demonstrated by the return of  the normal cortical pattern. Remodelling In children, and to a lesser degree in adults, bone remodels based on the forces passing through it. - Summary box 32.3 - Fracture healing - /uni25CF /uni25CF -
Direct – cortical apposition and absolute stability
Indirect – secondary bone healing, requires some movement

Thumb metacarpophalangeal ulnar collateral ligamen
Thumb metacarpophalangeal ulnar collateral ligament
Injury to the thumb metacarpal ulnar collateral ligament is a unique injury often termed ‘gamekeeper’s thumb’ or ‘skier’s thumb’. Owing to the unique anatomical arrangement of  adductor pollicis, if  the ligament undergoes complete rupture the aponeurosis may become interposed, inhibiting - - - - t the
(ai)
(aii)
(b)
(c)
(d)
Figure 32.21
Scaphoid fracture.
(a)
Anteroposterior
(i)
and lateral
(ii)
views in which the injury is dif
/f_i
cult to see;
(b, c)
oblique views with
the fracture line highlighted;
(d)
in this case of a young patient, the
fracture was treated with early
/f_i
xation.
Cap Rad Lun ligament-to-bone healing. A rupture of  the ulnar collateral ligament should be suspected when an ulna-directed force is directed across the metacarpophalangeal (MCP) joint. A tender swelling on the ulnar side of  the MCP joint may signify the Stener lesion. Increased laxity may be clinically evident; if  there is uncertainty , stress radiographs can demonstrate the degree of  injury . Complete ruptures with a Stener lesion (interposed aponeurosis) require open reduction of the liga ment to restore bone contact, with a suture anchor repair of the associated ulnar collateral ligament.
(b)
Figure 32.22
Perilunate dislocation.
(a)
A plain lateral radiograph of
the wrist;
(b)
the outline of the perilunate dislocation is highlighted.
Cap, capitate; Lun, lunate; Rad, radius.
Thumb metacarpophalangeal ulnar collateral ligament
Injury to the thumb metacarpal ulnar collateral ligament is a unique injury often termed ‘gamekeeper’s thumb’ or ‘skier’s thumb’. Owing to the unique anatomical arrangement of  adductor pollicis, if  the ligament undergoes complete rupture the aponeurosis may become interposed, inhibiting - - - - t the
(ai)
(aii)
(b)
(c)
(d)
Figure 32.21
Scaphoid fracture.
(a)
Anteroposterior
(i)
and lateral
(ii)
views in which the injury is dif
/f_i
cult to see;
(b, c)
oblique views with
the fracture line highlighted;
(d)
in this case of a young patient, the
fracture was treated with early
/f_i
xation.
Cap Rad Lun ligament-to-bone healing. A rupture of  the ulnar collateral ligament should be suspected when an ulna-directed force is directed across the metacarpophalangeal (MCP) joint. A tender swelling on the ulnar side of  the MCP joint may signify the Stener lesion. Increased laxity may be clinically evident; if  there is uncertainty , stress radiographs can demonstrate the degree of  injury . Complete ruptures with a Stener lesion (interposed aponeurosis) require open reduction of the liga ment to restore bone contact, with a suture anchor repair of the associated ulnar collateral ligament.
(b)
Figure 32.22
Perilunate dislocation.
(a)
A plain lateral radiograph of
the wrist;
(b)
the outline of the perilunate dislocation is highlighted.
Cap, capitate; Lun, lunate; Rad, radius.

Thumb metacarpophalangeal ulnar collateral ligament
Thumb metacarpophalangeal ulnar collateral ligament
Injury to the thumb metacarpal ulnar collateral ligament is a unique injury often termed ‘gamekeeper’s thumb’ or ‘skier’s thumb’. Owing to the unique anatomical arrangement of  adductor pollicis, if  the ligament undergoes complete rupture the aponeurosis may become interposed, inhibiting - - - - t the
(ai)
(aii)
(b)
(c)
(d)
Figure 32.21
Scaphoid fracture.
(a)
Anteroposterior
(i)
and lateral
(ii)
views in which the injury is dif
/f_i
cult to see;
(b, c)
oblique views with
the fracture line highlighted;
(d)
in this case of a young patient, the
fracture was treated with early
/f_i
xation.
Cap Rad Lun ligament-to-bone healing. A rupture of  the ulnar collateral ligament should be suspected when an ulna-directed force is directed across the metacarpophalangeal (MCP) joint. A tender swelling on the ulnar side of  the MCP joint may signify the Stener lesion. Increased laxity may be clinically evident; if  there is uncertainty , stress radiographs can demonstrate the degree of  injury . Complete ruptures with a Stener lesion (interposed aponeurosis) require open reduction of the liga ment to restore bone contact, with a suture anchor repair of the associated ulnar collateral ligament.
(b)
Figure 32.22
Perilunate dislocation.
(a)
A plain lateral radiograph of
the wrist;
(b)
the outline of the perilunate dislocation is highlighted.
Cap, capitate; Lun, lunate; Rad, radius.

Tibial plateau fractures
Tibial plateau fractures
Intra-articular fractures of  the tibial plateau are common. Injuries may involve the lateral or medial side or both. The joint articular surface may be split, depressed or a combination of both. A CT scan should be performed to see the full extent of  the injury . Undisplaced fractures may be treated non-operatively with a hinged knee brace and progressive protected weight- bearing over 8–12 weeks. The surgical considerations here are to restore alignment and joint congruity . Displaced fractures require reduction and stabilisation. The articular surface, once reduced, is often held with plate and screw ﬁxation or ﬁne wire external ﬁxation. For an undisplaced non-comminuted fracture of  the tibial shaft, closed reduction and an above-knee cast is a safe and inexpensive treatment. At 4–6 weeks this may be converted to a patellar tendon below-knee cast to allow knee movement. Prolonged casting can lead to sti ﬀ ness of  the knee and the subtalar joint. Cast treatment requires close and constant monitoring of  the position of  the fracture site. To correct minor angular deformities the cast can be wedged. A patient may choose to have an intramedullary nail to allow free knee and ankle movement. This, however, risks infection of the implant and anterior knee pain. T his is another situation in which information and shared decision making can allow the patient to select the most appropriate treatment option. For comminuted and complex fractures of  the tibial shaft, although cast treatment is possible, intramedullary nailing is preferred despite the potential complications of  infection and anterior knee pain. Fractures at the diaphyseal–metaphyseal junction at the knee and ankle are di ﬃ cult to hold with an intramedullary nail and as such may be held with a plate and screws. Tibial fractures are also very amenable to external ﬁxation with either a monolateral frame or ﬁne wire circular construct, particularly where surgical skills and implants are not available for intramedullary nailing. Tibial plateau fractures
Intra-articular fractures of  the tibial plateau are common. Injuries may involve the lateral or medial side or both. The joint articular surface may be split, depressed or a combination of both. A CT scan should be performed to see the full extent of  the injury . Undisplaced fractures may be treated non-operatively with a hinged knee brace and progressive protected weight- bearing over 8–12 weeks. The surgical considerations here are to restore alignment and joint congruity . Displaced fractures require reduction and stabilisation. The articular surface, once reduced, is often held with plate and screw ﬁxation or ﬁne wire external ﬁxation. For an undisplaced non-comminuted fracture of  the tibial shaft, closed reduction and an above-knee cast is a safe and inexpensive treatment. At 4–6 weeks this may be converted to a patellar tendon below-knee cast to allow knee movement. Prolonged casting can lead to sti ﬀ ness of  the knee and the subtalar joint. Cast treatment requires close and constant monitoring of  the position of  the fracture site. To correct minor angular deformities the cast can be wedged. A patient may choose to have an intramedullary nail to allow free knee and ankle movement. This, however, risks infection of the implant and anterior knee pain. T his is another situation in which information and shared decision making can allow the patient to select the most appropriate treatment option. For comminuted and complex fractures of  the tibial shaft, although cast treatment is possible, intramedullary nailing is preferred despite the potential complications of  infection and anterior knee pain. Fractures at the diaphyseal–metaphyseal junction at the knee and ankle are di ﬃ cult to hold with an intramedullary nail and as such may be held with a plate and screws. Tibial fractures are also very amenable to external ﬁxation with either a monolateral frame or ﬁne wire circular construct, particularly where surgical skills and implants are not available for intramedullary nailing. Tibial plateau fractures
Intra-articular fractures of  the tibial plateau are common. Injuries may involve the lateral or medial side or both. The joint articular surface may be split, depressed or a combination of both. A CT scan should be performed to see the full extent of  the injury . Undisplaced fractures may be treated non-operatively with a hinged knee brace and progressive protected weight- bearing over 8–12 weeks. The surgical considerations here are to restore alignment and joint congruity . Displaced fractures require reduction and stabilisation. The articular surface, once reduced, is often held with plate and screw ﬁxation or ﬁne wire external ﬁxation. For an undisplaced non-comminuted fracture of  the tibial shaft, closed reduction and an above-knee cast is a safe and inexpensive treatment. At 4–6 weeks this may be converted to a patellar tendon below-knee cast to allow knee movement. Prolonged casting can lead to sti ﬀ ness of  the knee and the subtalar joint. Cast treatment requires close and constant monitoring of  the position of  the fracture site. To correct minor angular deformities the cast can be wedged. A patient may choose to have an intramedullary nail to allow free knee and ankle movement. This, however, risks infection of the implant and anterior knee pain. T his is another situation in which information and shared decision making can allow the patient to select the most appropriate treatment option. For comminuted and complex fractures of  the tibial shaft, although cast treatment is possible, intramedullary nailing is preferred despite the potential complications of  infection and anterior knee pain. Fractures at the diaphyseal–metaphyseal junction at the knee and ankle are di ﬃ cult to hold with an intramedullary nail and as such may be held with a plate and screws. Tibial fractures are also very amenable to external ﬁxation with either a monolateral frame or ﬁne wire circular construct, particularly where surgical skills and implants are not available for intramedullary nailing.

Tibial shaft fractures
Tibial shaft fractures
Tibial fractures in children are often very amenable to non-operative treatment, starting with an above-knee cast, followed by conversion to a Sarmiento patellar tendon somewhat limited; as such, less angular deformity (only 10–15°) can be accepted and no rotational deformity . Some shortening of  the tibia can be accepted as the tibia is expected to overgrow by 0.5 /uni00A0 cm in response to injury . If  it is not possible to hold the fracture in an acceptable position with a cast, then external ﬁxation, elastic stable intramedullary nailing (ESIN)/titanium elastic nails (TENS; thin ﬂexible nails inserted in the canal of a long bone to splint it) or plating is an option. Tibial shaft fractures
Tibial fractures in children are often very amenable to non-operative treatment, starting with an above-knee cast, followed by conversion to a Sarmiento patellar tendon somewhat limited; as such, less angular deformity (only 10–15°) can be accepted and no rotational deformity . Some shortening of  the tibia can be accepted as the tibia is expected to overgrow by 0.5 /uni00A0 cm in response to injury . If  it is not possible to hold the fracture in an acceptable position with a cast, then external ﬁxation, elastic stable intramedullary nailing (ESIN)/titanium elastic nails (TENS; thin ﬂexible nails inserted in the canal of a long bone to splint it) or plating is an option. Tibial shaft fractures
Tibial fractures in children are often very amenable to non-operative treatment, starting with an above-knee cast, followed by conversion to a Sarmiento patellar tendon somewhat limited; as such, less angular deformity (only 10–15°) can be accepted and no rotational deformity . Some shortening of  the tibia can be accepted as the tibia is expected to overgrow by 0.5 /uni00A0 cm in response to injury . If  it is not possible to hold the fracture in an acceptable position with a cast, then external ﬁxation, elastic stable intramedullary nailing (ESIN)/titanium elastic nails (TENS; thin ﬂexible nails inserted in the canal of a long bone to splint it) or plating is an option.